Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 26, Issue 4, pp 1230–1236 | Cite as

Patient age as a preoperative factor associated with tunnel enlargement following double-bundle anterior cruciate ligament reconstruction using hamstring tendon autografts

  • Shinya Yanagisawa
  • Masashi Kimura
  • Keiichi Hagiwara
  • Atsuko Ogoshi
  • Tomoyuki Nakagawa
  • Hiroyuki Shiozawa
  • Takashi Ohsawa
Knee
  • 213 Downloads

Abstract

Purpose

A few studies have detected associations of post-operative tunnel enlargement with sex, age, and the timing of anterior cruciate ligament reconstruction (ACLR). The aim of the present study was to investigate the correlation between post-operative tunnel enlargement following ACLR using hamstring tendon autografts and preoperative factors. The authors hypothesized that tunnel enlargement is associated with age in patients undergoing ACLR.

Methods

One hundred and six patients (male, n = 57; female, n = 49; mean age, 26.9 years) who underwent double-bundle ACL reconstruction were included in the present study. The time between injury and surgery was 26.3 ± 71.4 weeks. Computed tomographic scans of the operated knee were obtained at 2 weeks and 6 months after surgery. The area of the tunnel aperture was measured for the femoral anteromedial tunnel (FAMT), femoral posterolateral tunnel (FPLT), tibial anteromedial tunnel (TAMT), and tibial posterolateral tunnel. The percentage of tunnel area enlargement was defined as the area at 2 weeks after ACLR subtracted from the area at 6 months after ACLR and then divided by the area at 2 weeks after ACLR. Spearman’s correlation coefficient was calculated for each factor. The patients were divided into two groups based on age. Patients aged <40 and ≥40 years were assigned to Groups A and B, respectively. The differences in the outcomes and characteristics of the two groups were evaluated.

Results

The percentage of enlargement of the FAMT, FPLT, and TAMT was correlated with patient age (r = 0.31, p = 0.001; r = 0.24, p = 0.012; and r = 0.30, p = 0.002, respectively). In total, 87 and 19 knees were classified into Groups A and B, respectively, based on patient age. The percentage of enlargement of the FAMT was significantly higher in Group B than A (78 vs. 60%, respectively; p = 0.01). The percentage of enlargement of the TAMT was significantly higher in Group B than A (53 vs. 36%, respectively; p = 0.03).

Conclusion

The percentage of enlargement of the FAMT and TAMT was associated with patient age. These findings suggest the need to consider the possibility of tunnel enlargement when double-bundle ACLR is performed for patients aged >40 years. Age was a preoperative factor associated with tunnel enlargement.

Level of evidence

III.

Keywords

Anterior cruciate ligament reconstruction Hamstring tendon autografts Post-operative tunnel enlargement 

Introduction

Bone tunnel enlargement is a common complication after anterior cruciate ligament reconstruction (ACLR) with hamstring autografts [1, 5, 7]. The presence of large tunnels often severely complicates revision ACL surgery. Large tunnels may necessitate staged reconstruction and additional operative procedures that are associated with significantly high costs [5]. Thus, methods of reducing the risk of tunnel widening after ACL reconstruction are needed [1, 22].

Tunnel widening likely occurs due to a complex interplay between biological and mechanical factors. The mechanical causes may include a “bungee effect” due to extracortical femoral fixation [15, 30], bone tunnel positioning [13, 17, 18], and accelerated rehabilitation [26]. The biological factors involved may include synovial fluid-derived cytokines and inflammatory mediators, the patient’s bone quality, the graft choice, and cell necrosis induced by drilling [2, 4, 7, 12, 17, 21, 27]. A few studies have revealed an association of post-operative tunnel enlargement with sex, age, and the timing of ACLR [18, 28]. Weber et al. [28] reported that a younger age (<30 years) may be associated with a risk of enlargement. In contrast, Segawa et al. [18] reported that patients aged >40 years showed tunnel enlargement when ACLR was performed using hamstring tendon autografts. However, the study focused on single-bundle ACLR and did not investigate the association between these factors and post-operative tunnel enlargement in patients undergoing double-bundle ACLR.

The aim of the present study was to investigate the correlation between post-operative tunnel enlargement following double-bundle ACLR using hamstring tendon autografts and preoperative factors. The authors hypothesized that tunnel enlargement is associated with age in patients undergoing double-bundle ACLR. To the best of the authors’ knowledge, this is the first study to investigate the association between age and post-operative tunnel enlargement in patients undergoing double-bundle ACLR.

Materials and methods

One hundred and fifty-two consecutive patients with ACL-deficient knees who underwent double-bundle reconstruction from April 2013 to August 2014 were retrospectively reviewed. Patients who underwent ACLR in both knees and those with an open physis were excluded from the study. Patients with a concomitant grade 3 medial or lateral collateral ligament injury were also excluded. Post-operative three-dimensional (3D) computed tomography (CT) was performed in all patients to rule out malpositioning of the tibial and femoral tunnels. The final study population included 57 men and 49 women. The mean patient age was 26.9 years. The time between injury and surgery was 26.3 ± 71.4 weeks.

Surgical procedure

Anatomic double-bundle ACLR was performed using a hamstring tendon according to the concept of anatomic double-bundle reconstruction [31]. If the diameter of either the anteromedial (AM) or posterolateral (PL) graft was <6 mm, the gracilis tendons were added. An EndoButton CL fixation device (Smith and Nephew Endoscopy, Andover, MA) was attached at the looped end, and a Telos artificial ligament (Telos, Marburg, Germany) was attached at the other end. The AM and PL femoral tunnels were made behind the resident’s ridge [9, 20], just anterior to the cartilage margin, using the outside-in technique. The authors determined that the AM tibial tunnel insertion should be lateral to the medial intercondylar ridge and posterior to the transverse ligament or Parsons’ knob [3] at 90° of knee flexion. A 2.4-mm guidewire was inserted into the AM tunnel. A 5.0- to 7.0-mm tunnel was then drilled over the guidewire for the AM tunnel. A 2.4-mm guidewire for the PL tunnel was then inserted slightly posterolaterally from the AM tunnel. Stapling was performed on the tibial side at 30° of knee flexion for graft fixation. Tibial fixation of the AM and PL bundles was carried out with 30 N of traction applied to each bundle [16].

Post-operative rehabilitation

A continuous passive motion machine was used from post-operative day 2. Partial weight-bearing activity (one-third of the patient’s body weight) was permitted from post-operative week 2. Full-body weight-bearing was permitted from post-operative week 4. Jogging was started 4 months after surgery. Full-speed running was allowed 6 months after surgery. A complete return to competitive sports was allowed 8 months after surgery.

Post-operative evaluation

All of the patients underwent a clinical examination 1 year after surgery. The side-to-side difference (SSD) in the anterior translation was investigated using a Telos device, and the Tegner activity scale (TAS) score was determined [25].

CT evaluation

Area measurement

CT scans of the operated knee were obtained at both 2 weeks and 6 months after surgery for all patients using a helical high-speed CT machine (SCENARIA; Hitachi Medical Systems, Tokyo, Japan). The settings were as follows: collimation, 16 × 0.625 mm; tube parameters, 175 mA and 120 kV; acquisition matrix, 512 × 512; field of view, 140 mm, and slice thickness, 0.5 mm. The images were evaluated and cross-sectional data obtained using a special software package (VOX BASE; J-MAC System, Sapporo, Japan). Cross-sectional measurements were calculated in a manner similar to that described in previously published work [24]. The CT scout view (at a level parallel to the outer rim of the lateral femoral condyle and intercondylar fossa of the tibia) was used. Sagittal reconstruction was performed at a level parallel to the outer rim of the lateral femoral condyle. To obtain the cross-sectional area, a slice was made 2 mm deep near the opening of the femoral bone tunnel and measured as the bone tunnel area (Fig. 1). Axial reconstruction was performed parallel to the outer rim of the intercondylar fossa of the tibia. To obtain the cross-sectional area, a slice was made 2 mm deep near the opening of the tibial bone tunnel and measured as the bone tunnel area (Fig. 2). The tunnel wall was traced within the bony margin, and the tunnel area surrounded by trace lines was measured. The value was then presented as the cross-sectional area of the tunnel in square millimetres (mm2) to the first decimal place (Fig. 3). The percentage of tunnel area enlargement was calculated by subtracting the area at 2 weeks after ACLR from the area at 6 months after ACLR and then dividing the value by the area at 2 weeks after ACLR. The reliability calculations were performed using the cross-sectional areas. Two orthopaedic surgeons (independent observers) developed and agreed to the measurement methods together; however, they were blinded to each other’s measurements and their previous measurements. The intraobserver and interobserver reliability ranged from 0.77 to 0.94 and 0.63 to 0.90, respectively.
Fig. 1

Sagittal reconstruction was performed at a level parallel to the outer rim of the lateral femoral condyle. To obtain the cross-sectional area, a slice was made 2 mm deep near the opening of the femoral bone tunnel and measured as the bone tunnel area

Fig. 2

Axial reconstruction was performed parallel to the outer rim of the intercondylar fossa of the tibia. To obtain the cross-sectional area, a slice was made 2 mm deep near the opening of the tibial bone tunnel and measured as the bone tunnel area

Fig. 3

Tunnel wall was traced within the bony margin, and the tunnel area surrounded by trace lines was measured. The value was then presented as the cross-sectional area of the tunnel in square millimetres (mm2) to the first decimal place

Tunnel location

At 2 weeks after surgery, the femoral tunnel position was measured by the femoral quadrant method [14], and the tibial tunnel position was measured by the tibial quadrant method using 3D CT [14].

Institutional review board approval for the study was provided by Zensyukai Hospital (No. 28060801).

Statistical analyses

Spearman’s correlation coefficients were calculated. The patients were divided into two groups based on age to conduct a comparative study. Patients aged <40 and ≥40 years were assigned to Groups A and B, respectively. The differences between the two groups were evaluated. The Chi-square test was used to compare categorical variables, and the Mann–Whitney U test (a nonparametric method) was used to compare continuous variables.

Post hoc tests showed that the power of the percentage of enlargement of the FAMT, which was the primary outcome of the present study, was 0.65 with a significance level of 0.05 [8].

Results

The demographic and clinical characteristics of each group are shown in Table 1.
Table 1

Patient demographics and preoperative and post-operative data

Sex (male/female)

57/49

BMI (kg/m2)

23.1 ± 3.4

Time between injury and surgery (weeks)

26.3 ± 71.4

Preoperative TAS score

7.0 ± 1.9

Post-operative TAS score

6.8 ± 1.9

Preoperative SSD (mm)

7.7 ± 3.4

Post-operative SSD (mm)

1.4 ± 1.9

Percentage of enlargement of FAMT (%)

63.4 ± 34.6

Percentage of enlargement of FPLT (%)

70.2 ± 43.9

Percentage of enlargement of TAMT (%)

39.2 ± 29.4

Percentage of enlargement of TPLT (%)

47.8 ± 32.4

Position of FAMT (%)

 Deep–shallow

20.2 ± 3.0

 Low–high

29.8 ± 7.0

Position of FPLT (%)

 Deep–shallow

32.9 ± 6.0

 Low–high

55.8 ± 6.0

Position of TAMT (%)

 Anteroposterior

22.2 ± 4.0

 Mediolateral

44.9 ± 2.0

Position of TPLT (%)

 Anteroposterior

40.0 ± 5.0

 Mediolateral

46.5 ± 2.0

With the exception of sex, all data are presented as mean ± standard deviation

BMI body mass index, TAS Tegner activity scale, SSD side-to-side difference, FAMT femoral anteromedial tunnel, FPLT femoral posterolateral tunnel, TAMT tibial anteromedial tunnel, TPLT tibial posterolateral tunnel

The percentage of enlargement of the femoral AM tunnel (FAMT), femoral PL tunnel, and tibial AM tunnel (TAMT) was associated with patient age. No significant associations were observed between the percentage of enlargement and the other parameters.

Based on age, 87 knees were classified into Group A and 19 knees were classified into Group B. There were no significant differences between the two groups in terms of sex (Group A, 50.1% male; Group B, 42.1% male) or body mass index. There were no significant differences between the two groups in terms of the preoperative and post-operative SSD. The preoperative and post-operative TAS scores were significantly lower in Group B than A (p = 0.001). The percentage of enlargement of the FAMT was significantly higher in Group B than A (p = 0.01). The percentage of enlargement of the TAMT was also significantly higher in Group B than A (p = 0.03). No significant difference in tunnel position was observed between the two groups (Table 2).
Table 2

Comparison of clinical findings between Groups A and B

 

Group A (n = 87)

Group B (n = 19)

p value

Sex (male/female)

43/44

11/8

n.s.

BMI (kg/m2)

23.0 ± 3.6

23.3 ± 2.7

n.s.

Time between injury and surgery (weeks)

24.3 ± 61.4

35.3 ± 107.8

n.s.

Preoperative TAS score

7.3 ± 1.7

5.3 ± 1.8

0.001

Post-operative TAS score

7.4 ± 3.3

5.5 ± 1.6

0.001

Preoperative SSD (mm)

7.4 ± 3.3

9.0 ± 4.0

n.s.

Post-operative SSD (mm)

1.5 ± 0.9

1.8 ± 2.2

n.s.

Percentage of enlargement of FAMT (%)

60.1 ± 34.1

78.5 ± 34.0

0.03

Percentage of enlargement of FPLT (%)

67.1 ± 40.9

84.2 ± 55.7

n.s.

Percentage of enlargement of TAMT (%)

36.3 ± 25.6

53.6 ± 41.1

0.03

Percentage of enlargement of TPLT (%)

46.4 ± 32.3

54.8 ± 32.9

n.s.

Position of FAMT (%)

 Deep–shallow

20.0 ± 3.0

21.3 ± 3.0

n.s.

 Low–high

29.7 ± 7.0

30.2 ± 7.0

n.s.

Position of FPLT (%)

 Deep–shallow

32.6 ± 6.0

34.6 ± 6.0

n.s.

 Low–high

55.9 ± 6.0

55.4 ± 5.0

n.s.

Position of TAMT (%)

 Anteroposterior

22.1 ± 4.0

23.5 ± 5.0

n.s.

 Mediolateral

44.7 ± 2.0

45.7 ± 2.0

n.s.

Position of TPLT (%)

 Anteroposterior

40.0 ± 5.0

40.9 ± 7.0

n.s.

 Mediolateral

46.5 ± 2.0

46.5 ± 2.0

n.s.

With the exception of sex, all data are presented as mean ± standard deviation

BMI body mass index, TAS Tegner activity scale, SSD side-to-side difference, FAMT femoral anteromedial tunnel, FPLT femoral posterolateral tunnel, TAMT tibial anteromedial tunnel, TPLT tibial posterolateral tunnel, n.s. not significant

Discussion

The most important findings of the present study are that age was associated with enlargement of the FAMT and TAMT and that the TBIS and TAS score were not associated with tunnel enlargement. Despite the clinical recognition of bone tunnel enlargement, its origin and natural history are not fully understood. Tunnel enlargement likely occurs due to a complex interplay of biological and mechanical factors. Mechanical causes may include nonanatomic tunnel placement [13, 17, 18], micromotion at the tunnel aperture when soft tissue grafts are used with suspensory fixation [5, 29], increased stress at the tunnel–graft interface [19], or aggressive rehabilitation [26]. Although the preoperative factors that may be associated with post-operative bone tunnel enlargement are still not fully understood, a possible association between younger age (<30 years) and a risk of enlargement was reported in one study [28]. However, the sample size of that study was relatively small (18 cases), and the patients’ mean age (35.5 years) differed from that in the present study (26.9 years). In contrast, Segawa et al. [18] reported that patients aged >40 years showed tunnel enlargement in patients who were undergoing single-bundle ACLR using hamstring tendon autografts. In the present study, age was associated with enlargement of the FAMT and TAMT in patients who were undergoing double-bundle ACLR. Although this result might have occurred due to the patients’ bone mineral density, no studies have revealed an association between tunnel enlargement and bone mineral density. Thus, further investigations are needed.

Bone tunnel enlargement also reportedly depends on the positioning of the bone tunnel [13, 18]. An association between a more anterior and higher femoral tunnel position and widening of the femoral tunnel was reported by Ko et al. [13]. In the present study, no significant differences were found in the tunnel position between the two groups.

Additionally, the present study revealed no association between the TBIS and tunnel enlargement. In contrast to the present results, another study showed that a delay from injury to ACLR may increase the risk of enlargement [28]. However, the mean TBIS in that study was approximately 134 weeks, while the mean TBIS in the present study was 26 weeks. This difference might have been responsible for the discrepancy in the findings of the present study.

A few studies have reported on the association between the TAS score and post-operative tunnel enlargement. Weber et al. [28] reported that there was no significant association between the TAS score and tunnel enlargement. Although no significant associations were found between the objective measures of tunnel enlargement and the TAS score, it is possible that this lack of differences was due to the low statistical power of the study.

The effect of tunnel widening on graft function and knee laxity remains unclear. No statistically significant associations between the objective measures of knee laxity and tunnel enlargement were found, which is generally consistent with previous studies [5, 10, 29]. However, at least one study has revealed a positive relationship between tunnel expansion and knee laxity [11]. In contrast, the association between the preoperative SSD and bone tunnel enlargement was not investigated. In the present study, the preoperative SSD was not associated with tunnel enlargement.

Weber et al. [28] reported that the aperture of both the tibial and femoral tunnels generally increased until the 24th week after surgery. Thus, 2-week and 6-month post-operative CT scans of the operated knee were examined. In addition, considering the influence of each patient’s physical size, the percentage of tunnel enlargement on these CT scans was examined.

The present study has several limitations that warrant mention. First, the patients’ bone mineral density, which might have affected tunnel enlargement, was not assessed. Second, the follow-up period was only 1 year. However, although the follow-up period was short, tunnel enlargement was generally increased 24 weeks post-operatively. Third, the low statistical power of the study might have been the reason for the lack of significant differences between certain variables. Fourth, tunnel enlargement was evaluated on 2D CT and not 3D CT. Recent studies have shown that the use of 3D CT might be beneficial for evaluating the size of the bone tunnels after ACL reconstruction [6, 23]. Fifth, this study was retrospective in nature. Finally, the patients were not compared with other groups of patients, such as those undergoing anatomic single-bundle reconstruction or patients in whom interference screw fixation techniques were applied.

Several previous reports have examined tunnel enlargement after ACLR. However, the strengths of the present study are that the patients in the two groups were comparable in terms of sex, graft type, and surgical technique and that they underwent the same rehabilitation programme. The findings of this study suggest the need for surgeons to be aware of the possibility of tunnel enlargement when double-bundle ACLR is performed for patients aged >40 years.

Conclusion

The percentage of enlargement of the FAMT and TAMT was associated with the age of patients undergoing double-bundle ACLR using hamstring tendon autografts. Patient age was one of the preoperative factors associated with tunnel enlargement.

Notes

Compliance with ethical standards

Conflict of interest

The authors declare no conflict of interest in association with the present study.

Funding

No external source of funding was used.

Ethical approval

Institutional review board approval for the study was provided by Zensyukai Hospital (No. 28060801).

Informed consent

Informed consent has been obtained by all study objects.

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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2017

Authors and Affiliations

  • Shinya Yanagisawa
    • 1
  • Masashi Kimura
    • 1
  • Keiichi Hagiwara
    • 1
  • Atsuko Ogoshi
    • 1
  • Tomoyuki Nakagawa
    • 1
  • Hiroyuki Shiozawa
    • 1
  • Takashi Ohsawa
    • 2
  1. 1.Zensyukai Hospital Gunma Sports Medicine Research CenterMaebashiJapan
  2. 2.Department of Orthopaedic SurgeryGunma University Graduate School of MedicineMaebashiJapan

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