Abstract
Purpose
The aetiology and clinical significance of enlargement of bone tunnels following anterior cruciate ligament (ACL) reconstruction remains controversial. This phenomenon has been attributed to biological factors and mechanical factors.
We wanted to study the amount of femoral and tibial tunnel enlargement 5 years post-ACL reconstruction. By standardizing the type of femoral fixation, we also wanted to determine whether the type of tibial fixation had any bearing to the amount of tibial tunnel enlargement.
Methods
All patients who underwent arthroscopic hamstring autograft ACL reconstruction between January 2000 and December 2000 were identified. All grafts were fixed with close-looped endobutton proximally. The grafts were fixed on the tibial side with staples or bioabsorbable interference screws.
At a minimum of 5 years after surgery, these patients were recalled. They were assessed with Lysholm knee, Tegner activity and the IKDC Subjective and Objective forms and a KT-1000 arthrometer. The diameter of the bone tunnels and tunnel positions in the anterior–posterior and lateral radiographs were measured using digital callipers by a two blinded researchers.
Results
We found that the femoral tunnel enlarged more than the tibial tunnel. At 5 years, the mean tibial tunnel enlargement was 2.46 mm and the mean femoral tunnel enlargement was 3.23 mm. All 54 patients had endobutton femoral fixation. Of them, 34 patients had tibial graft fixation with staples (extracortical fixation) and 20 patients had tibial graft fixation with bioabsorbable interference screws (aperture fixation). The mean enlargement as measured by the two independent observers in the extracortical group was 1.98 mm (24.7 %)* and 1.51 mm (18.2 %)**compared to 3.27 mm (40.4 %)* and 2.92 mm (30.0 %)** in the aperture fixation group. This difference in tibial tunnel enlargement between the groups was significant (p < 0.001, mean difference 1.29 mm). However, this was not correlated with any significant difference in clinical outcome at 5 years.
Conclusion
We, like some authors, have shown that the use of interference screws in tibial fixation despite being aperture fixation actually has a greater amount of tibial enlargement. This lends weight to the biological theory to tunnel enlargement.
Similar content being viewed by others
Notes
* ICC refers to intraclass correlation coefficient
** CI refers to confidence interval.
References
Hoher J, Moller HD, Fu FH (1998) Bone tunnel enlargement after anterior cruciate ligament reconstruction: fact or fiction? Knee Surg Sports Traumatol Arthrosc 6:231–240
Clatsworthy MG, Annear P, Bulow JU, Bartlett RJ (1999) Tunnel widening in anterior cruciate ligament reconstruction: a prospective evaluation of hamstring and patella tendon grafts. Knee Surg Sports Traumatol Arthrosc 7:138–145
Webster KE, Feller JA, Hamiester KA (2001) Bone tunnel enlargement following anterior cruciate ligament reconstruction: a randomised comparison of hamstring and patellar tendon grafts with 2 year follow-up. Knee Surg Sports Traumatol Arthrosc 9:86–91
Dyer CR, Elrod BF (1994) Tibial and femoral bone tunnel enlargement after anterior cruciate ligament replacement. Am J Sports Med 22:410–414
Kobayashi M, Nakagawa Y, Suzuki T, Okudaira S, Nakamura T (2006) A retrospective review of bone tunnel enlargement after anterior cruciate ligament reconstruction with hamstring tendons fixed with a metal round cannulated interference screw in the femur. Arthroscopy 22:1093–1099
Peyrache MD, Djian P, Christel P, Witvoet J (2006) Tibial tunnel enlargement after anterior cruciate ligament reconstruction by autogenous bone patellar bone graft. Knee Surg Sports Traumatol Arthrosc 4:2–8
Ma CB, Francis K, Towers J et al (2004) Hamstring anterior cruciate ligament reconstruction: a comparison of bioabsorbable interference screw and endobutton-post fixation. Arthroscopy 20:122–128
Jackson DW, Windler GE, Simon TM (1980) Intraarticular reaction associated with freeze dried, ethylene oxide-sterilized bone patellar tendon bone allografts in the reconstruction of the anterior cruciate ligament. Am J Sports Med 18:1–10
Roberts TS, Drez D, McCarthy W, Paine R (1991) Anterior cruciate ligament reconstruction using freeze dried, ethylene-oxide sterilized bone patellar tendon bone allografts. Am J Sports Med 19:35–41
Freidman RJ, Black J, Galante JO, Jacobs JJ, Skinner HB (1994) Current concepts in orthopedic biomaterials and implant fixation. Instr Course Lect 43:233–235
Amiel D, Kleiner JB, Akeson WH (1986) The natural history of the anterior cruciate ligament autograft of patellar tendon origin. Am J Sports Med 14:449–462
Giron F, Aglietti P, Cuomo Mondanelli N, Ciardullo A et al (2005) Anterior cruciate ligament reconstruction with doubled- looped semi-tendinosus and gracilis tendon graft directly fixed to cortical bone: 5 year results. Knee Surgery Sports Traumatol Arthrosc 13:81–91
Insalata J, Klatt B, Fu FH, Harner CD (1997) Tunnel expansion following anterior cruciate ligament reconstruction: a comparison of hamstring and patellar tendon autografts. Knee Surg Sports Traumatol Arthrosc 5:234–238
Segawa H, Omori G, Tomita S, Koga Y (2001) Bone tunnel enlargement after anterior cruciate ligament reconstruction using hamstring tendons. Knee Surg Sports Traumatol Arthrosc 9:206–210
Jansson KA, Harilainen A, Sandelin J, Karjalainen PT, Aronen HJ, Tallroth K (1999) Bone tunnel enlargement after anterior cruciate ligament reconstruction with hamstring autograft and endobutton fixation technique. Knee Surg Sports Traumatol Arthrosc 7:290–295
Nebelung W (1998) Bone tunnel enlargement after anterior cruciate ligament reconstruction with semitendinosus tendon using endobutton fixation on femur side. Arthroscopy 14:810–815
Jagodzinski M, Foerstemann T, Mall G, Krettek C, Bosch U, Paessler HH (2005) Analysis of forces of ACL reconstructions at the tunnel entrance: is tunnel enlargement a biomechanical problem? J Biomech 38:23–30
Weiler A, Hoffmann RF, Bail HJ (2002) Tendon healing in a bone tunnel. Part II: histologic analysis after biodegradable interference fit fixation in a model of anterior cruciate ligament reconstruction in sheep. Arthroscopy 18:124–135
Fauno P, Kaalund S (2005) Tunnel widening after hamstring anterior cruciate ligament reconstruction is influenced by type of graft fixation used: a prospective randomized study. Arthroscopy 21:1337–1341
Fink C, Zapp M, Bendetto P, Hackl W, Hoser C, Rieger M (2001) Tibial tunnel enlargement following anterior cruciate ligament reconstruction with patellar tendon allograft. Arthroscopy 17:138–143
Jo H, Jun DS, Lee DY, Lee SH, Seong SC, Lee MC (2004) Tibial tunnel area changes following arthroscopic anterior cruciate ligament reconstructions with autogenous patellar tendon graft. Knee Surg Sports Traumatol Arthrosc 12:311–316
Silva A, Sampaio R, Pinto E (2010) Femoral tunnel enlargement after anatomic ACL reconstruction: a biological problem? Knee Surg Sports Traumatol Arthrosc 18:1189–1194
Buelow JU, Siebold R, Ellermann A (2002) A prospective evaluation of tunnel enlargement in anterior cruciate ligament reconstruction with hamstrings: extracortical versus anatomical fixation. Knee Surg Sports Traumatol Arthrosc 10:80–85
Laxdal G, Kartus J, Eriksson B et al (2006) Biodegradable and metallic interference screws in Anterior Cruciate Ligament reconstruction surgery using hamstring grafts. Am J Sports Med 34:1574–1589
Robinson J, Huber C, Jaraj P, Colombet P, Allard M, Meyer P (2006) Reduced bone tunnel enlargement post hamstring ACL reconstruction with poly-l-lactic acid/hydroxyapatite bioabsorbable screws. Knee 13:127–131
Zysk SP, Fraunberger P, Veihelmann A, Dörger M, Kalteis T, Maier M, Pellengahr C, Refior HJ (2004) Tunnel enlargement and changes in synovial fluid cytokine profile following anterior cruciate ligament reconstruction with patellar tendon and hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc 12:98–103
Xu Y, Ao Y, Wang J, Yu J, Cui G (2011) Relation of tunnel enlargement and tunnel placement after single-bundle anterior cruciate ligament reconstruction. Arthroscopy 27:923–932
Neddermann A, Willbold W, Witte F, Hurschler C, Hankemeier S, Stübig T et al (2009) Tunnel widening after ACL reconstruction: an experimental study in sheep. Am J Sports Med 37:1609–1617
Quatman CE, Paterno MV, Wordeman SC, Kaeding CC (2011) Longitudinal anterior knee laxity related to substantial tibial tunnel enlargement after anterior cruciate ligament revision. Arthroscopy 27:1160–1163
Klein JP, Lintner DM, Downs D, Vavrenka K (2003) The incidence and significance of femoral tunnel widening after quadrupled hamstring anterior cruciate ligament reconstruction using femoral cross pin fixation. Arthroscopy 19:470–476
Thaunat M, Nourissat G, Gaudin P, Beaufils P (2006) Tibial plateau fracture after anterior cruciate ligament reconstruction: role of the interference screw resorption in the stress riser effect. Knee 13:241–243
Vadala A, Iorio R, De Carli A, Argento G, Di Sanzo V, Conteduca F et al (2007) The effect of accelerated, brace free, rehabilitation on bone tunnel enlargement after ACL reconstruction using hamstring tendons : a CT study. Knee Surg Sports Traumatol Arthrosc 15:365–371
Iorio R, Vadala A, Argento G, Di Sanzo V, Conteduca F, Ferretti A (2007) Bone tunnel enlargement after ACL reconstruction using autologous hamstring tendons: a CT study. Int Orthop 31:49–55
Webster KE, Feller JA, Elliot J, Hutchison A, Payne R (2004) A comparison of bone tunnel measurements made using computer tomography and digital plain radiography after anterior cruciate ligament reconstruction. Arthroscopy 20:946–950
Conflict of interest
We the authors hereby declare that we do not have any conflict of interest with the contents of this article submitted.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Dave, L.Y.H., Leong, O.K., Karim, S.A. et al. Tunnel enlargement 5 years after anterior cruciate ligament reconstruction: a radiographic and functional evaluation. Eur J Orthop Surg Traumatol 24, 217–223 (2014). https://doi.org/10.1007/s00590-013-1175-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00590-013-1175-4