The Graft Insertion Length in the Femoral Tunnel during ACL Reconstruction with Suspensory Fixation and Tibialis Anterior Allograft does not Affect Surgical Outcomes, but is Negatively Correlated with Tunnel Widening

Background: Arthroscopically aided anterior cruciate ligament reconstruction using hamstring graft can be fixed to femoral condyle by suspensory and aperture fixation methods. The following study was undertaken to investigate whether there is any difference in functional outcomes with these fixation methods as measured by the Lysholm knee score and to determine tunnel widening post operatively with these two methods and does it affect the functional outcome.Methods: 50 patients of clinically and radiologic ally diagnosed ACL tear fulfilling the inclusion and exclusion criteria were randomized into two groups to undergo arthroscopic ACL reconstruction using quadrupled hamstring graft with suspensory (n=25) and aperture (n=25) fixation methods on femoral side. They were compared post operatively with Lysholm score, clinical laxity tests and percentage of tunnel enlargement using computed tomograms at 01 year.Results: At the end of 6 months there was no much difference in Lysholm score between both the groups (P =0.663) and at the end of 01 year aperture group had slightly better outcome. However, the difference was not statistically significant (p =0.173). There was more tunnel widening in the suspensory group especially of the femoral tunnel in the coronal plane. However, the amount of tunnel widening in both the groups was not significant statistically (P =0.071 and P =0.963). Tunnel widening is not associated with inferior clinical outcomes or functional knee score.Conclusions: Aperture and Suspensory fixation methods of hamstring graft at femoral condyle in ACL reconstruction are comparable clinically and there is no advantage of one particular method over other. Although comparatively more tunnel widening is seen in suspensory fixation methods; it does not affect the final clinical outcomes or functional knee scores.

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Computed Tomography Imaging Results of Single Band Anterior Cruciate Ligament Reconstruction: A Retrospective Study Comparing Fixed- and Adjustable-Length Loop Cortical Fixation on the First Day After Surgery

10.21203/rs.3.rs-660355/v1 ◽

2021 ◽

Author(s):

Lifeng Yin ◽

Hua Zhang ◽

Junbo Liu ◽

xingyu zhang ◽

zhengxing wen ◽

...

Keyword(s):

Computed Tomography ◽

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Femoral Tunnel ◽

Cruciate Ligament ◽

Ct Images ◽

Graft Fixation ◽

Bone Preservation ◽

Anterior Cruciate ◽

Graft Insertion

Abstract Background: Cortical suspensory femoral fixation is commonly performed for graft fixation of the femur in anterior cruciate ligament (ACL) reconstruction using hamstring tendons. This study aimed to compare the morphology of femoral tunnel and graft insertion between fixed-length loop devices (FLD) and adjustable-length loop devices (ALD) using computed tomography (CT) images on the first day after hamstring ACL reconstruction. Methods: Overall, 94 patients who underwent ACL reconstruction from January 2016 to January 2021 were included. For femoral graft fixation, FLD (Smith & Nephew, ENDOBUTTON) and ALD (DePuy Synthes, Mitek sports medicine, RIGIDLOOP Adjustable cortical system) were used in 56 and 38 patients, respectively (FLD and ALD groups). For evaluation of the morphology of the humeral tunnel and graft depth, CT scans were performed immediately on the first postoperative day. The gap distance between the top of the graft and the socket tunnel end, the length of lateral bone preservation, and the depth of graft insertion were measured on the CT images. Results: The gap distance and bone preservation significantly differed between the two groups (1.90±1.81 mm and 14.35±4.67 mm in ALD groups; 7.08±2.63 mm and 7.35±3.62 mm in FLD groups, respectively; both P values < 0.01). The graft insertion depth did not significantly differ between the groups. Conclusion: The ALD group had a smaller gap distance, better bone preservation, and a similar graft insertion length in the femoral tunnel when compared to the FLD group. Based on these findings, ALD might be better for bone preservation and tunnel utilization in patients with short femoral tunnels. Trial registration: retrospectively registered

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Influence of Graft Bending Angle on Femoral Tunnel Widening After Double-Bundle ACL Reconstruction: Comparison of Transportal and Outside-In Techniques

Orthopaedic Journal of Sports Medicine ◽

10.1177/23259671211035780 ◽

2021 ◽

Vol 9 (10) ◽

pp. 232596712110357

Author(s):

Do Kyung Lee ◽

Jun Ho Kim ◽

Byung Hoon Lee ◽

Hyeonsoo Kim ◽

Min Jae Jang ◽

...

Keyword(s):

Clinical Outcomes ◽

Acl Reconstruction ◽

Femoral Tunnel ◽

Pearson Correlation ◽

Double Bundle ◽

Tunnel Widening ◽

Bending Angle ◽

Graft Bending Angle ◽

Significant Difference ◽

Double Bundle Acl Reconstruction

Background: Previous studies have suggested that increased mechanical stress due to acute graft bending angle (GBA) is associated with tunnel widening and graft failure after anterior cruciate ligament (ACL) reconstruction. Few studies have compared the GBA between the outside-in (OI) and the transportal (TP) techniques. Purpose: To evaluate the influence of GBA on clinical outcomes and tunnel widening after ACL reconstruction with OI versus TP technique. Study Design: Cohort study; Level of evidence, 3. Methods: Included in the study were 56 patients who underwent double-bundle ACL reconstruction (n = 28 in the OI group and n = 28 in the TP group). Clinical outcomes (Lysholm, International Knee Documentation Committee, Tegner score, and knee laxity) 1 year postoperatively were evaluated. Computed tomography scans at 5 days and 1 year postoperatively were used for imaging measurements, and the femoral tunnel was divided into the proximal third, middle, and aperture sections. The GBA and cross-sectional area (CSA) were measured using image analysis software and were compared between groups. A correlation analysis was performed to determine if the GBA affected clinical outcomes or tunnel widening. Results: No significant difference was observed in clinical outcomes between the groups. The GBA of both the anteromedial (AM) and posterolateral bundles were more acute in the OI group compared with the TP group ( P < .05). The CSA at the AM tunnel aperture increased significantly in the OI group (84.2% ± 64.3%) compared with the TP group (51.4% ± 36.7%) ( P = .04). However, there were no differences in the other sections. In the Pearson correlation test, GBA was not correlated with tunnel widening or clinical outcomes. Conclusion: Regardless of technique, the GBA did not have a significant influence on tunnel widening or clinical outcomes. Considering a wider AM tunnel aperture, a more proximal and posterior AM tunnel position might be appropriate with the OI technique.

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The Potentially Positive Role of PRPs in Preventing Femoral Tunnel Widening in ACL Reconstruction Surgery Using Hamstrings: A Clinical Study in 51 Patients

Journal of Sports Medicine ◽

10.1155/2014/789317 ◽

2014 ◽

Vol 2014 ◽

pp. 1-10 ◽

Cited By ~ 4

Author(s):

Konstantinos A. Starantzis ◽

Dimitrios Mastrokalos ◽

Dimitrios Koulalis ◽

Olympia Papakonstantinou ◽

Panayiotis N. Soucacos ◽

...

Keyword(s):

Acl Reconstruction ◽

Femoral Tunnel ◽

Platelet Rich Plasma ◽

Cruciate Ligament ◽

Randomized Study ◽

Tunnel Widening ◽

Double Blind ◽

Reconstruction Surgery ◽

Significant Difference

Purpose. In this study, the early and midterm clinical and radiological results of the anterior cruciate ligament (ACL) reconstruction surgery with or without the use of platelet rich plasma (PRP) focusing on the tunnel-widening phenomenon are evaluated.Methods. This is a double blind, prospective randomized study. 51 patients have completed the assigned protocol. Recruited individuals were divided into two groups: a group with and a group without the use of PRPs. Patients were assessed on the basis of MRI scans, which were performed early postoperatively and repeated at least one-year postoperatively. The diameter was measured at the entrance, at the bottom, and at the mid distance of the femoral tunnel.Results. Our study confirmed the existence of tunnel widening as a phenomenon. The morphology of the dilated tunnels was conical in both groups. There was a statistical significant difference in the mid distance of the tunnels between the two groups. This finding may support the role of a biologic response secondary to mechanical triggers.Conclusions. The use of RPRs in ACL reconstruction surgery remains a safe option that could potentially eliminate the biologic triggers of tunnel enlargement. The role of mechanical factors, however, remains important.

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Computed Tomography Imaging of BioComposite Interference Screw After ACL Reconstruction With Bone–Patellar Tendon–Bone Graft

Orthopaedic Journal of Sports Medicine ◽

10.1177/23259671211006477 ◽

2021 ◽

Vol 9 (5) ◽

pp. 232596712110064

Author(s):

Brian Scrivens ◽

Melissa A. Kluczynski ◽

Marc S. Fineberg ◽

Leslie J. Bisson

Keyword(s):

Computed Tomography ◽

Acl Reconstruction ◽

Femoral Tunnel ◽

Tibial Tunnel ◽

Cyst Formation ◽

Tunnel Widening ◽

Cross Sectional ◽

Interference Screws ◽

Computed Tomography Scans ◽

Tunnel Size

Background: Bioabsorbable interference screws tend to have high resorption rates after anterior cruciate ligament (ACL) reconstruction; however, no studies have examined screws composed of 30% biphasic calcium phosphate and 70% poly-d-lactide (30% BCP/70% PLDLA). Purpose: To evaluate femoral and tibial tunnel widening and resorption of 30% BCP/70% PLDLA interference screws and replacement with bone at 2 to 5 years after ACL reconstruction using bone–patellar tendon–bone (BTB) autograft. Study Design: Case series; Level of evidence, 4. Methods: Included were 20 patients who had undergone ACL reconstruction using BTB autograft and were reevaluated 2 to 5 years after surgery using computed tomography scans. Tunnel measurements were obtained from computed tomography scans in the sagittal and coronal planes and were compared with known tunnel measurements based on operative reports. These images and measurements were used to assess tunnel widening, resorption of the 30% BCP/70% PLDLA screw, its replacement with bone, and possible cyst formation. Paired t tests were used to compare initial and final femoral and tibial tunnel measurements. Results: The cross-sectional area of the femoral tunnel decreased at the aperture ( P = .03), middle ( P = .0002), and exit ( P < .0001) of the tunnel compared with the initial femoral tunnel size, and the tibial tunnel cross-sectional area decreased at the aperture ( P < .0001) and exit ( P = .01) of the tunnel compared with the initial tibial tunnel size. Bone formation was observed in 100% of femoral tunnels and 94.7% of tibial tunnels. Screw resorption was 100% in the femur and 94.7% in the tibia at the final follow-up. Cysts were noted around the femoral tunnel in 2 patients (5.1%). Conclusion: The 30% BCP/70% PLDLA interference screws used for ACL reconstruction using BTB autograft had high rates of resorption and replacement with bone, and there were no increases in tunnel size at 2 to 5 years postoperatively. The authors observed a low rate of cyst formation and no other adverse events stemming from the use of this specific biointerference screw, suggesting that this type of screw is a reasonable option for graft fixation with minimal unfavorable events and a reliable resorption profile.

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Bone tunnel impaction reduced the tibial tunnel enlargement

Open Medicine ◽

10.1515/med-2017-0016 ◽

2017 ◽

Vol 12 (1) ◽

pp. 99-106 ◽

Cited By ~ 2

Author(s):

Huan Xu ◽

Rongzong Zheng ◽

Jinhe Ying

Keyword(s):

Acl Reconstruction ◽

Tibial Tunnel ◽

Hamstring Tendon ◽

Bone Tunnel ◽

Tunnel Widening ◽

Tunnel Enlargement ◽

Fixation Devices ◽

Suspensory Fixation ◽

Group A ◽

The Mean

AbstractThe purpose of this study was to investigate whether the bone tunnel impaction technique performed by dilators could dwindle the tibial tunnel enlargement after anterior cruciate ligament (ACL) reconstruction with hamstring tendon using both extracortical suspensory fixation devices at femoral and tibial site.Thirty-one consecutive patients undergoing primary ACL reconstruction with the hamstring autograft were enrolled in this research. Patients were randomly allotted to group A (bone tunnel impaction technique using dilators) or group B (regular extraction bone tunnel drilling).ResultsThe average follow-up was 16.2 months. The mean femoral tunnel widening was 1.05 mm and 1.02 mm respectively in group A and B. The mean tibial tunnel widening was 0.61 mm and 1.08 mm respectively in group A and B. There was no statistical difference for tunnel enlargement between the two groups at the femoral site (P = 0.62) but significant difference at the tibial site (P < 0.0001).ConclusionBone tunnel impaction technique leaded to a reduction of tibial bone tunnel enlargement after ACL reconstruction with hamstring tendon using both extracortical suspensory fixation devices at femoral and tibial site.

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PEDIATRIC ACL RECONSTRUCTION: DOES THE FEMORAL PEEK IMPLANT CAUSE TUNNEL WIDENING?

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119s00189 ◽

2019 ◽

Vol 7 (3_suppl) ◽

pp. 2325967119S0018

Author(s):

Lydia Saad ◽

Guy Grimard ◽

Marie-Lyne Nault

Keyword(s):

Acl Reconstruction ◽

Femoral Tunnel ◽

Cruciate Ligament ◽

Chemical Properties ◽

Bone Tunnel ◽

Reference Points ◽

University Hospital ◽

Tunnel Widening ◽

Tunnel Enlargement

Background: Because of their strength, inertness and biocompatibility, polyetherketone (PEEK) implants have been increasingly used in orthopedics, especially trauma and spine surgeries. Their mechanical and chemical properties have been widely studied and compared to other materials since their accelerated development in the 1980s. Their use is relatively new in anterior cruciate ligament reconstructions (ACLR), and there is little literature to document their effect on tunnel widening in these procedures. Bone tunnel enlargement following ACLR is a widely reported phenomenon that has been negatively correlated with clinical outcome scores. A recent prospective study reiterated its stronger association with suture discs compared with methods using interference screws, cross-pins and buttons. There is only one paper that specifically reports the results of a study on PEEK implants in relation with tunnel widening and it did not demonstrate significant association. PEEK polymer has not yet been studied in pediatric knees, in which tunnel widening has more than the usual residual laxity and re-tear implications, as it can also cause physeal damage. The purpose of this study was to investigate the use of a femoral PEEK implant in ACLR performed on skeletally immature patients and to determine if it is associated with tunnel widening. As a secondary objective, this study aimed to assess the risk of growth complications associated with the use of PEEK. Methods: All patients who underwent all-epiphyseal ACLR surgery in a pediatric university hospital between March 2015 and January 2017 were included in this retrospective study. The all-epiphyseal ACL reconstruction procedures were done using a new instrumentation system that includes a titanium tibial anchor fixation and a femoral PEEK screw system. Femoral bone tunnel diameters were measured on postoperative lateral knee radiographs. The widest tunnel measurements were taken using the sclerotic tunnel margins as reference points and compared to the known sizes of the drill bits retrieved from operative protocols. Paired t tests were performed to assess bone tunnel widening. P-values <0.05 were considered significant. SPSS 25.0 was used for statistical analysis. Results: Eighteen (19 knees) arthroscopic ACL reconstruction patients were included. Of the 18 all-epiphyseal ACL reconstruction patients, 4 (22.2%) were female and 14 (77.8%) were male. The chronological and bone ages at time of surgery (mean ± SD) were respectively 13.5 ± 1.6 and 13.3 ± 1.0 years. At a mean follow-up of 17.1 months, average tunnel enlargement was 1.8± 1.4 (0.0-4.2) mm at the femur and was found to be statistically significant (P<0.001). There were no symptomatic growth abnormalities requiring intervention, but 2 unilateral early physeal closures at the distal femur (10.5%) were noted. These patients had notable femoral tunnel enlargement. One had a 3.0 mm of femoral tunnel widening and no observable growth disturbance. The other had an asymptomatic and non-progressive unilateral knee valgum of 5 degrees and 3.5 mm of femoral tunnel widening. Conclusions/significance: This study showed that the largest tunnel increase at a mean follow up of 17.1 months was 4.2 mm. It is not clear that this widening is clinically significant even though it is statistically significant. Also, association between femoral tunnel widening and physeal closure could not be formally established. Thus, further research on this potential risk factor is needed.

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Femoral Tunnel Widening Via Transcondylar Cross-Pin Fixation Versus Extracortical Suspensory Fixation After Single-Bundle ACLR: A Systematic Review and Meta-analysis

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967121993811 ◽

2021 ◽

Vol 9 (4) ◽

pp. 232596712199381

Author(s):

Haluk Celik ◽

Jun-Ho Kim ◽

Sang-Hak Lee ◽

Dae-Hee Lee

Keyword(s):

Systematic Review ◽

Femoral Tunnel ◽

Cruciate Ligament ◽

Meta Analysis ◽

Fixation Method ◽

Tunnel Widening ◽

Single Bundle ◽

Pin Fixation ◽

Significant Difference ◽

Suspensory Fixation

Background: Compared with extracortical suspensory fixation, the close-to-joint transcondylar cross-pin fixation method in anterior cruciate ligament reconstruction (ACLR) is believed to entail less intratunnel graft motion and subsequently lead to less tunnel widening. Purpose: To assess femoral tunnel widening via the transcondylar cross-pin method or the suspensory femoral fixation method in patients who had undergone ACLR. Study Design: Systematic review; Level of evidence, 4. Methods: This review focused on studies on femoral-tunnel widening after single-bundle ACLR with cross-pin (Rigidfix or Transfix) and/or Endobutton closed loop (CL). Two reviewers independently recorded data from each study, including the sample size and magnitude of tunnel widening after ACLR. Results: Overall, 19 studies were included in this meta-analysis. There was no significant difference between cross-pin and Endobutton CL fixations in the pooled absolute change in tunnel widening from the immediate postoperative period to the final follow-up; this was true at both the tunnel aperture (2.48 mm [95% CI, 1.76-3.2 mm] vs 2.93 mm [95% CI, 1.73-4.13 mm], respectively; P = .527) and the midpoint of the femoral tunnel (2.43 mm [95% CI, 1.77-3.1 mm] vs 2.54 mm [95% CI, –0.33 to 5.42 mm], respectively; P = .937). No significant difference was found in the relative percentage of femoral-tunnel widening between the 2 fixation methods (cross-pin, 43.3% [95% CI, 25.8%-60.8%] vs Endobutton CL, 42.0% [95% CI, 34.1%-49.9%]; P = .965). Conclusion: No significant difference in femoral tunnel widening was found to be associated with the use of either cross-pin or extracortical suspensory fixation in patients who underwent single-bundle ACLR.

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Comparison of femoral tunnel widening between outside-in and trans-tibial double-bundle ACL reconstruction

Knee Surgery Sports Traumatology Arthroscopy ◽

10.1007/s00167-013-2597-6 ◽

2013 ◽

Vol 22 (9) ◽

pp. 2033-2039 ◽

Cited By ~ 5

Author(s):

Yong Seuk Lee ◽

Beom Koo Lee ◽

Won Seok Oh ◽

Yong Kyun Cho

Keyword(s):

Acl Reconstruction ◽

Femoral Tunnel ◽

Double Bundle ◽

Tunnel Widening ◽

Double Bundle Acl Reconstruction

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Comparison of tunnel widening between interference screw and suture disc fixation after ACL reconstruction using CT scan

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20180510 ◽

2018 ◽

Vol 4 (2) ◽

pp. 266

Author(s):

Athar Ahemad ◽

Anand B. Anerao

Keyword(s):

Ct Scan ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Interference Screw ◽

Bone Tunnel ◽

Tunnel Widening ◽

Tunnel Enlargement ◽

Suspensory Fixation ◽

The Difference ◽

Student’S T

Background: It is important to study the cause of tunnel widening which occurs after anterior cruciate ligament (ACL) reconstruction as it may affect tendon to bone healing. Amount of tunnel enlargement that happens after different fixation methods like interference screw or suture discs needs to be compared.The objective of the study was to test the hypothesis that aperture fixation (interference screw) reduces tunnel enlargement compared to suspensory fixation (suture disc) due to reduced graft tunnel motion.Methods: 24 bone tunnel diameters in 12 patients were evaluated by CT scan postoperatively after ACL reconstruction to measure tunnel widening. Two groups were formed, one consisting of 14 tunnels fixed by interference screws (IFS) and other consisting of 10 tunnels fixed with suture disc (SD). The difference between the two groups was compared by unpaired student’s t test.Results: The mean tunnel widening in IFS group was 0.414mm while that in the SD group was 1.23mm. The difference between the means of the two groups was statistically significant (p<0.001). Conclusions: Tunnel widening phenomenon was significantly less with anatomic IFS fixation as compared to suture disc fixation probably due to reduced motion of graft within the walls of bony tunnel and consequently better graft healing.

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