This is a retrospective case report of three cases with an early postoperative transtibial fistula after anterior cruciate ligament reconstruction (ACL).
Materials and methods
The patients had undergone ACL reconstruction and complained of fluid drainage through the not-healed wound or swelling localized on the anteromedial aspect of the ipsilateral proximal tibia during the early postoperative. Magnetic resonance imaging showed a multilocular fluid-filled cyst arising from the distal hole of the tibial bone tunnel. Open resection of the fistula and the cyst was performed in all cases and communication between the tibial tunnel and the joint space was confirmed. During revision surgery the distal hole of the tibial tunnel was covered with a fascio-periosteal flap.
All wounds healed without complications. There was no recurrence of drainage or cyst formation. At 2 years follow-up the knee function was normal and was not affected by the complication in any of the patients. Early postoperative transtibial fistulae after ACL reconstruction are rare complications that clinically present either as anterior tibial cysts or persistent wound drainage. Surgical treatment is required, and some delay in the rehabilitation routine is required, but the final outcome is not affected.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
Mather RC 3rd, Koenig L, Kocher MS, Dall TM, Gallo P, Scott DJ, Bach BR Jr, Spindler KP (2013) Societal and economic impact of anterior cruciate ligament tears. J Bone Joint Surg Am 95(19):1751–1759
Cohen SB, Sekiya JK (2007) Allograft safety in anterior cruciate ligament reconstruction. Clin Sports Med 26(4):597–605
Ahlden M, Samuelsson K, Sernert N, Forssblad M, Karlsson J, Kartus J (2012) The Swedish national anterior cruciate ligament register: a report on baseline variables and outcomes of surgery for almost 18,000 patients. Am J Sports Med 40(10):2230–2235
Kartus J, Magnusson L, Stener S, Brandsson S, Eriksson BI, Karlsson J (1999) Complications following arthroscopic anterior cruciate ligament reconstruction. A 2–5-year follow-up of 604 patients with special emphasis on anterior knee pain. Knee Surg Sports Traumatol Arthrosc 7(1):2–8
Benedetto KP, Fellinger M, Lim TE, Passler JM, Schoen JL, Willems WJ (2000) A new bioabsorbable interference screw: preliminary results of a prospective, multicenter, randomized clinical trial. Arthroscopy 16(1):41–48
Martinek V, Friederich NF (1999) Tibial and pretibial cyst formation after anterior cruciate ligament reconstruction with bioabsorbable interference screw fixation. Arthroscopy 15(3):317–320
Malhan K, Kumar A, Rees D (2002) Tibial cyst formation after anterior cruciate ligament reconstruction using a new bioabsorbable screw. Knee 9(1):73–75
Brettler D, Soudry M (1995) Tibial bone plug resorption with extra-articular cyst: a rare complication of anterior cruciate ligament reconstruction. Arthroscopy 11(4):478–481
Feldmann DD, Fanelli GC (2001) Development of a synovial cyst following anterior cruciate ligament reconstruction. Arthroscopy 17(2):200–202
Brager MA, Traina SM, Parker AW (2002) Pretibial cyst following anterior cruciate ligament reconstruction using hamstring autografts. Orthopedics 25(1):79–82
Deie M, Sumen Y, Ochi M, Murakami Y, Fujimoto E, Ikuta Y (2000) Pretibial cyst formation after anterior cruciate ligament reconstruction using auto hamstring grafts: two case reports in a prospective study of 89 cases. Magn Reson Imaging 18(8):973–977
Ghazikhanian V, Beltran J, Nikac V, Feldman M, Bencardino JT (2012) Tibial tunnel and pretibial cysts following ACL graft reconstruction: MR imaging diagnosis. Skeletal Radiol 41(11):1375–1379
Victoroff BN, Paulos L, Beck C, Goodfellow DB (1995) Subcutaneous pretibial cyst formation associated with anterior cruciate ligament allografts: a report of four cases and literature review. Arthroscopy 11(4):486–494
Simonian PT, Wickiewicz TL, O’Brien SJ, Dines JS, Schatz JA, Warren RF (1998) Pretibial cyst formation after anterior cruciate ligament surgery with soft tissue autografts. Arthroscopy 14(2):215–220
Ruiz-Iban MA, Diaz Heredia J, Cebreiro Martinez Val I, Alonso Guemes S, Cuellar Gutierrez R, Sastre Solsona S (2013) Evolution of C-reactive protein values in the first month after anterior cruciate ligament reconstruction: reference values. Knee Surg Sports Traumatol Arthrosc
Tegner Y, Lysholm J (1985) Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 198:43–49
Lysholm J, Gillquist J (1982) Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med 10(3):150–154
Johnston M, Morse A, Arrington J, Pliner M, Gasser S (2011) Resorption and remodeling of hydroxyapatite-poly-l-lactic acid composite anterior cruciate ligament interference screws. Arthroscopy 27(12):1671–1678
Ilahi OA, Younas SA, Sahni IK (2003) Pretibial cyst formation after arthroscopic anterior cruciate ligament reconstruction. Arthroscopy 19(2):E5
Sekiya JK, Elkousy HA, Fu FH (2004) Recurrent pretibial ganglion cyst formation over 5 years after anterior cruciate ligament reconstruction. Arthroscopy 20(3):317–321
Tsuda E, Ishibashi Y, Tazawa K, Sato H, Kusumi T, Toh S (2006) Pretibial cyst formation after anterior cruciate ligament reconstruction with a hamstring tendon autograft. Arthroscopy 22(6):691–696
Ramsingh V, Prasad N, Lewis M (2014) Pre-tibial reaction to biointerference screw in anterior cruciate ligament reconstruction. Knee 21(1):91–94
Apostolopoulos A, Nikolopoulos D, Polyzois I, Liarokapis S, Rossas C, Michos I (2012) Pretibial cyst formation after anterior cruciate ligament reconstruction with poly-L acid screw fixation: a case report presentation and review of the literature. J Surg Orthop Adv 21(3):151–156
Roberts TS, Drez D Jr, McCarthy W, Paine R (1991) Anterior cruciate ligament reconstruction using freeze-dried, ethylene oxide-sterilized, bone-patellar tendon-bone allografts. Two year results in thirty-six patients. Am J Sports Med 19(1):35–41
Gonzalez-Lomas G, Cassilly RT, Remotti F, Levine WN (2011) Is the etiology of pretibial cyst formation after absorbable interference screw use related to a foreign body reaction? Clin Orthop Relat Res 469(4):1082–1088
Conflict of interest
There are no conflicts of interest.
About this article
Cite this article
Díaz Heredia, J., Ruiz Iban, M.A., Cuéllar Gutiérrez, R. et al. Early postoperative transtibial articular fistula formation after anterior cruciate ligament reconstruction: a review of three cases. Arch Orthop Trauma Surg 134, 829–834 (2014). https://doi.org/10.1007/s00402-014-1988-6