Femoral Tunnel Widening Research Articles

Lateral extra-articular tenodesis does not enhance ACL graft healing, however, does reduce graft tunnel widening.

The study hypothesized that the addition of lateral extra-articular tenodesis (LEAT) in anterior cruciate ligament reconstruction (ACLR) had a significant effect on ACL graft healing. A total of 80 patients were divided into two cohorts matched for gender, age, body mass index, time from surgery to post-operative MRI and graft diameter. Forty patients underwent ACL reconstruction alone, while 40 underwent ACLR in addition to LEAT. Patients underwent a magnetic resonance imaging scan at 12 months post-surgery; tunnel apertures were measured using multiplanar reformation, graft healing was assessed using signal-to-noise quotient (SNQ) in three regions of interest and finally graft maturity and integration were classified using the Howell and Ge scale, respectively. In addition, clinical evaluation and patient-reported outcome measures were collected. The mean femoral tunnel widening at 12 months post-surgery was 39.8 ± 14.0% in the ACLR + LEAT group and 55.2 ± 12.7% in the ACLR alone group (p < 0.05). The mean tibial tunnel widening was 29.3 ± 12.7% in the ACLR + LEAT group and 44.4 ± 12.1% in the ACLR group (p < 0.05). The mean adjusted graft SNQ was 9.0 ± 14.9 in the ACLR + LEAT group and 9.5 ± 11.4 in the ACLR group (n.s.). At 1 year post-operatively, we noted significantly less femoral and tibial tunnel widening in the ACLR + LEAT group. LEAT did not result in a statistically significant effect on graft healing. Level III.

Periosteal wrapping of the hamstring tendon autograft improves graft healing and prevents tunnel widening after anterior cruciate ligament anatomic reconstruction

IntroductionThe periosteum is a readily available tissue at the hamstring harvest site that could be utilized to enhance graft healing and prevent tunnel widening without additional cost or morbidity. This study aimed to compare graft healing using magnetic resonance imaging (MRI) and functional clinical outcome scores in a matched cohort of patients who underwent anterior cruciate ligament (ACL) reconstruction with hamstring autografts with or without periosteal augmentation.Material and methodsForty-eight patients who underwent ACL reconstruction (ACLR) were prospectively enrolled: 25 with standard ACLR (ST-ACLR) and 23 with periosteal augmented grafts (PA-ACLR). The same surgical techniques, fixation methods, and postoperative protocol were used in both groups. Signal-to-noise quotient (SNQ), graft healing at the bone-graft interface, graft signal according to the Howell scale, and femoral tunnel widening were evaluated using MRI after 1 year of follow-up. International knee documentation score (IKDC), Lysholm, Tegner activity scale, and visual analog scale for pain were used for functional evaluation at a minimum of 2 years postoperative.ResultsThe mean SNQ of the proximal part of the graft was 9.6 ± 9.2 and 2.9 ± 3.3 for the ST-ACLR and PA-ACLR groups, respectively (P = 0.005). The mean femoral tunnel widening was 30.3% ± 18.3 and 2.3% ± 9.9 for the ST-ACLR, PA-ACLR groups, respectively (P < 0.001). Complete graft tunnel healing was observed in 65% and 28% of cases in the PA-ACLR and ST-ACLR groups, respectively. Both groups showed marked improvements in functional scores, with no statistically significant differences.ConclusionPeriosteal wrapping of hamstring tendon autografts is associated with better graft healing and maturation and lower incidence of femoral tunnel widening based on MRI analysis 1 year after ACL reconstruction. However, patient-reported outcomes and measured laxity were similar between the two groups at 2 years follow up.Trial registrationTrail registration number: PACTR202308594339018, date of registration: 1/5/2023, retrospectively registered at the Pan African Clinical Trial Registry (pactr.samrc.ac.za) database.

Comparison of Cross-Pin Versus Cortical Button Femoral Fixation in Anterior Cruciate Ligament Reconstruction With Hamstrings Autograft: A Long-Term Clinical Study and Review of the Literature.

Background Anterior cruciate ligament reconstruction (ACLR) is a common operative procedure and many options regarding the type of the selected graft and fixation technique have been described to date. Although many studies have addressed the issue of the optimal femoral fixation device during ACLR with a hamstring tendon (HT) autograft, no clear evidence to indicate one technique over another has been found. Objective The purpose of this study was to compare the long-term postoperative outcomes and complication rates between transfemoral Cross-pin (CP) and Endobutton-Cortical Button (CB) fixation techniques in patients undergoing ACLR with an HT autograft. Methods One hundred and seven consecutive patients underwent ACLR by using a quadruple HT autograft that was stabilized with either a CP (CP Group: 52 patients) or a CB (CB Group: 55 patients) fixation technique. The Lachman test (LT), the Pivot-shift test (PST), the side-to-side difference in anterior translation of the tibia, the International Knee Documentation Committee (IKDC), and the Lysholm knee scoring systems were evaluated before surgery and during long-term follow up. Thefemoral and tibial tunnel diameter was measured in the anteroposterior (AP) and lateral radiographsafter surgery and at the final follow-up. Areview of the literature was also carried out to identify any differences between both techniques. Results Study groups were comparable in terms of patient demographics. The mean follow-up was 10.4 ± 1.3 and 10.6 ± 1.3 years in the CP and CB Groups, respectively (p = 0.47). In the CP Group, improvements after surgery in LT and PST from grade 2 (n=34) or 3 (n=18) to grade 0 (n = 41) or 1 (n = 11) and from grade 2 (n=36) or 3 (n = 16) to grade 0 (n = 44) or 1 (n = 8), respectively, were observed. In the CB Group, similar improvements in LT and PST scores from grade 2 (n = 40) or 3 (n = 15) to grade 0 (n = 46) or 1 (n = 9) and from grade 2 (n = 41) or 3 (n = 14) to grade 0 (n = 47) or 1 (n = 8), respectively, were observed. However, no differences between the groups (p = 0.53 for LT and p = 0.90 for PST) were noted. The mean Lysholm scores were 89.7 ± 6.8 and 90.2 ± 7.2 in the CP and CB groups, respectively (p = 0.59). Side-to-side difference improved from 9.1 ± 2.8 to 1.7 ± 1.5 mm and from 8.6 ± 2.5 to 1.6 ± 1.4 mm in the CP and CB groups, respectively (p = 0.89 between groups). According to IKDC grades, 92.1% and 91.4% of knees in the CP and CB groups, respectively were reported to be Grade A (Normal) or B (Nearly Normal) with a p = 0.7. Femoral and tibial tunnel widening was found in the last follow-up in both groups. However, there was no difference in the degree of tunnel widening among the two techniques.With respect to LT, PST, anterior drawer test, and IKDC score, none of the 15 published comparative studies demonstrated any significant differences between the two techniques and only one study detected a difference regarding the Lysholm score in favor of CP fixation. Conclusion In the long term, both CB and CP femoral stabilization techniques were shown to be associated with similar functional outcomes and low complication rates. Further large multicenter random clinical trials are still required to identify the most effective method of femoral fixation for HT autograft during ACLR surgery.

Comparison of the Clinical Outcomes between All-inside and Standard Technique in Anterior Cruciate Ligament Reconstruction with 6-strand Hamstring Tendon Autograft.

All-inside and standard techniques with 4-strand hamstrings graft have been widely used in anterior cruciate ligament (ACL) reconstruction. However, the graft diameter of less than 8 mm will significantly increase the rate of surgical failure, and the 6-strand graft can solve this problem. The purpose of this study is to compare all-inside ACL reconstruction using suspensory cortical button fixation on both tibia and femur with standard ACL reconstruction using suspensory femoral fixation and a bioabsorbable tibial interference screw with a 6-strand hamstring tendon autograft in postoperative clinical outcomes. From January 2020 to December 2020, 48 patients performed ACL reconstruction were divided into the all-side group and the standard group according to the different surgical techniques. Magnetic resonance imaging (MRI) and subjective function scores was used to assess clinical outcomes at least 24 months following ACL reconstruction. MRI was used to measure the value of bone tunnel widening in articular and middle portions. Subjective function scores included the Lysholm knee score, the International Knee Documentation Committee (IKDC) score, the Knee Society Score (KSS) for pain and function, and KT-1000. The t-test was used assuming the distribution of the patients which follows the normal distribution and we used non-parametric tests if these two conditions were not satisfied. At the final follow-up, there were 22 patients in the all-inside group and 24 patients in the standard group. No significant differences were found with respect to femoral tunnel widening and subjective function scores. However, a significant increase in tibial tunnel widening was found in the middle portion of the standard group (2.25 ± 0.74) compared to the all-inside group (0.76 ± 0.24) (p < 0.01) and also in the articular portion of the standard group (2.07 ± 0.77) compared to the all-inside group (1.52 ± 0.54) (p = 0.02). In addition, the value of the KT-1000 was 1.81 ± 0.45 for the all-inside group and 2.12 ± 0.44 in the standard group (p = 0.016). The objective stability of the knee was relatively better in the all-inside group than in the standard group. And tunnel widening after ACL reconstruction was significantly greater in the standard technique when compared to the all-inside technique on the tibia side.

Serial change of femoral and tibial tunnel width after anterior cruciate ligament reconstruction with allograft.

To investigate progressive tunnel widening and its correlation with postoperative outcomes after anterior cruciate ligament (ACL) reconstruction using allografts. Sixty-five patients who underwent ACL reconstruction using a tibialis anterior allograft between 2015 and 2017 were enrolled. Femoral and tibial tunnel widths were measured on anteroposterior (AP) and lateral radiographs immediately and at 3, 6, 12, and 24months postoperatively. Average femoral and tibial tunnel widths in AP and lateral views were calculated at three different measurement points. Tunnel widening was calculated as the difference in tunnel width immediately and 2years postoperatively. The correlation between tunnel widening and the postoperative results was analysed. Tunnel width changes between immediate and 2years postoperatively were as follows, in AP and lateral views, respectively: femur, 3.0mm ± 1.5mm and 2.4mm ± 1.4mm; and tibia, 2.8mm ± 1.4mm and 2.9mm ± 1.5mm. Femoral tunnel widths significantly increased until 1year, but not from 1 to 2years postoperatively. Tibial tunnel width significantly increased until 2years postoperatively. In all tunnels, the increments in tunnel widening decreased over time. Increased knee laxity significantly correlated with greater femoral tunnel widening in AP (r = 0.346, P = 0.006) and lateral views (r = 0.261, P = 0.049). Femoral tunnel widths gradually increased until 1year postoperatively, and tibial tunnel widths increased until 2years after ACL reconstruction with allografts. The tunnel widening rate gradually decreased over time. Femoral tunnel widening of 3.7mm and 3.2mm on AP and lateral views, respectively, were the cut-off values for postoperative knee laxity. Level III.

Influence of Meniscal Repair vs. Meniscectomy on Anterior Cruciate Ligament Reconstruction in Terms of Knee Stability and Radiological Imaging.

The menisci are essential components in the pathophysiology of knee osteoarthritis. Patients with meniscal lesions and an intact anterior cruciate ligament (ACL) undergoing meniscectomy exhibit a significantly increased prevalence of radiographic osteoarthritis. ACL reconstruction surgery enhances knee stability and mitigates the advancement of minor meniscal tears. The purpose of this study was to show the influence of meniscal repair as compared to meniscectomy on anterior cruciate ligament reconstruction in terms of knee stability and radiological imaging. This was a retrospective study performed in Dr. D.Y. Patil Hospital, Pimpri, Pune, on a sample size of 30 patients between December 2021 and January 2023. Patients were followed up clinically and radiologically post-operatively at six months and one year. ACL reconstruction with meniscectomy was performed on 16 patients (group 2), while ACL reconstruction with meniscus repair was performed on 14 patients (group 1). At the end of six months in group 1, one patient out of 14 had a grade 2 Lachman test positive, while seven patients out of 16 had a grade 2 Lachman test positive in group 2. It was a statistically insignificant value (p>0.05). Further, at the end of 12 months, X-ray evaluation of the femoral tunnel shows an average increment of 0.5 mm in Group 1, while an average femoral tunnel widening of 3 mm was observed in Group 2. It was statistically insignificant (p>0.05). The study concluded that meniscus repair significantly increases anteromedial knee stability. It has been shown that meniscectomy, when done along with ACL reconstruction, increases the chances of femoral tunnel widening, resulting in less graft bone integration.

Beneficial Effect of Curved Dilator System for Femoral Tunnel Creation in Preventing Femoral Tunnel Widening after Anterior Cruciate Ligament Reconstruction.

Backgrounds and objectives: A prevalent concern in anterior cruciate ligament (ACL) reconstruction is postoperative tunnel widening. We hypothesized that employing a curved dilator system (CDS) for femoral tunnel creation can reduce this widening after ACL reconstruction compared to the use of a conventional rigid reamer. Materials and Methods: A retrospective study was conducted involving 56 patients who underwent primary ACL reconstruction between January 2012 and July 2013. The patients were categorized into two groups: the reamer group (n = 28) and CDS group (n = 28). All participants were followed up for a minimum of 2 years. Clinical assessment included the Lachman test and pivot-shift test, and the Lysholm score and subjective International Knee Documentation Committee scores. Radiographic evaluation covered the tunnel widening rate, represented as the ratio of the tunnel diameter 2 years after surgery to the tunnel diameter immediately after surgery, and the ratio (A/B) of femoral tunnel (A) to tibial tunnel (B) diameters at respective time points. Results: No significant disparities were found between the two groups in terms of clinical outcomes. However, the reamer group exhibited a greater femoral tunnel widening rate compared to the CDS group (reamer group vs. CDS group: 142.7 ± 22.0% vs. 128.0 ± 19.0% on the anteroposterior (AP) radiograph and 140.8 ± 14.2% vs. 122.9 ± 13.4% on the lateral radiograph; all p < 0.05). Two years post-operation, the A/B ratio rose in the reamer group (0.96 ± 0.05→1.00 ± 0.05 on the AP radiograph and 0.94 ± 0.03→1.00 ± 0.0.04 on the lateral radiograph; all p < 0.05), while it decreased in the CDS group (0.99 ± 0.02→0.96 ± 0.05 on the AP radiograph and 0.97 ± 0.03→0.93 ± 0.06 on the lateral radiograph; all p < 0.05). Conclusion: The use of CDS for femoral tunnel creation in primary ACL reconstruction provides a potential advantage by limiting tunnel widening compared to the conventional rigid-reamer approach.

Human Trials on the Prevention of Tunnel Widening by the Emdogain in Anterior Cruciate Ligament Reconstruction.

Background Although anterior cruciate ligament reconstruction (ACLR) is an established procedure, some problems remain, such as bone tunnel widening after ACLR. In animal studies, Emdogain (EMD) prevented tunnel widening by promoting tendon-bone healing. This study aimed to evaluate the effects of EMD on the prevention of tunnel widening after anterior cruciate ligament (ACL) injury in humans. Methods Nineteen patients who underwent ACLR were included. Seven patients in the EMD group were administered EMDs into the femoral tunnel during ACLR, while 12 patients in the control group were not administered EMDs. After surgery, at two and four weeks and three, six, and 12 months, femoral and tibial tunnel widening were evaluated on computed tomography images. Anteroposterior laxity and clinical scores such as the Lysholm score, the International Knee Documentation Committee (IKDC) subjective form, and the Knee Injury and Osteoarthritis Outcome Score (KOOS) were assessed beforesurgery and 12 months postoperatively. Results Tunnel widening on the femoral side was significantly smaller in the EMD group than in the control group at two weeks. However, there was no significant difference between the two groups at 12 months. There were no significant differences in anteroposterior laxity and clinical scores between the groups before and 12 months after surgery. Conclusion EMD administration into the bone tunnel did not prevent tunnel widening at 12 months after ACLR, although tunnel widening of the femoral tunnel was reduced by EMD administration in the early phase.

Femoral Tunnel Position Affects Postoperative Femoral Tunnel Widening after Anterior Cruciate Ligament Reconstruction with Tibialis Anterior Allograft

This study aims to identify potential factors for both femoral and tibial tunnel widening (TW) and to investigate the effect of TW on postoperative outcomes after anterior cruciate ligament (ACL) reconstruction with a tibialis anterior allograft. A total 75 patients (75 knees) who underwent ACL reconstruction with tibialis anterior allografts were investigated between February 2015 and October 2017. TW was calculated as the difference in tunnel widths between the immediate and 2-year postoperative measurements. The risk factors for TW, including demographic data, concomitant meniscal injury, hip-knee-ankle angle, tibial slope, femoral and tibial tunnel position (quadrant method), and length of both tunnels, were investigated. The patients were divided twice into two groups depending on whether the femoral or tibial TW was over or less than 3 mm. Pre- and 2-year follow-up outcomes, including the Lysholm score, International Knee Documentation Committee (IKDC) subjective score, and side-to-side difference (STSD) of anterior translation on stress radiographs, were compared between TW ≥ 3 mm and TW < 3 mm. The femoral tunnel position depth (shallow femoral tunnel position) was significantly correlated with femoral TW (adjusted R2 = 0.134). The femoral TW ≥ 3 mm group showed greater STSD of anterior translation than the femoral TW < 3 mm group. The shallow position of the femoral tunnel was correlated with the femoral TW after ACL reconstruction using a tibialis anterior allograft. A femoral TW ≥ 3 mm showed inferior postoperative knee anterior stability.

Low Femoral Tunnel Widening Incidence Rate After ACL Reconstruction Using Patellar Tendon Graft with Press-Fit Fixation

BackgroundFemoral tunnel widening after ACL reconstruction is a common phenomenon. We hypothesized that using a patellar tendon graft with a press-fit fixation technique without any fixation device reduces the incidence of femoral tunnel widening.MethodsThis study was conducted on 467 patients with ACL surgery between 2003 and 2015. Two hundred and nineteen of them had an ACL surgery with patellar tendon (PT) graft, and two hundred and forty-eight of them with hamstring tendon (HS). Exclusion criteria were history of previous ACL reconstruction of either knee, multiple ligament injury, or evidence of osteoarthritis on radiographs. The femoral tunnels were measured on the anteroposterior (ap) and lateral radiographs 6 months after the operation. Two independent orthopedic surgeons measured all radiographs twice and recorded the tunnel widenings. We hypothesized that using an implant-free press-fit technique with PT graft can reduce the femoral tunnel widening incidence rate.ResultsThe mean incidence rate of the tunnel widening in the HS group was, on the AP and the lateral femoral views, 88% (n = 217) and 83% (n = 205), while in the PT group, 17% (n = 37) and 2% (n = 4), respectively. There was a significant difference both on AP and lateral radiographs (HS vs. PT: fem. AP: 89% vs. 17% p < 0.001; HS vs. PT: fem. lat: 84% vs. 2% p < 0.001).ConclusionThe femoral tunnel widening incidence rate during an ACL reconstruction is significantly less when using PT tendon with femoral press-fit fixation than when using HT tendon with suspensory fixation method.

Clinical effect of morphological changes in bone tunnels after anterior cruciate ligament reconstruction

Background: The effect of tunnel widening on clinical outcomes after anterior cruciate ligament (ACL) reconstruction has not been widely investigated. In this study, ACL reconstructions (ACL-Rs) were done by semitendinosus and gracilis tendon grafts and suspensory fixation on the femoral side. The aim was to study tunnel widening at the end of 1 year postoperative and correlate it with clinical outcomes. Materials and Methods: Fifty-five consecutive patients enrolled in the study underwent arthroscopic ACL-R. All were evaluated clinically using the Lysholm knee score and Tegner activity level preoperatively as well as during subsequent follow-up. Femoral and tibial tunnels were visualized with computed tomography scan which was performed at a mean duration of 1 year (range: 10–14 months). Results: The mean femoral tunnel diameter increased significantly (17.1%) from 8.03 ± 0.05 mm postoperatively to 9.04 ± 0.6 mm at 1 year; the tibial tunnel increased significantly (22.55%) from 9.04 ± 0.04 mm to 11.09 ± 0.8 mm at the same duration. No significant correlation could be established between tunnel widening and clinical evaluation scores. In both clinical evaluation scales, the overall improvement was noticed. Conclusions: Within a limit, neither femoral nor tibial tunnel widening affects the clinical outcome at 1 year of follow-up.

After MPFL reconstruction, femoral tunnel widening and migration increase with poor tunnel positioning and are related to poor clinical outcomes.

Isolated MPFL reconstruction (iMPFLR) is increasingly used for the surgical treatment of treatment for recurrent patella dislocation. The purpose of this study was to evaluate the influence of tunnel widening and migration on clinical outcomes after iMPFL using a CT-scannographic analysis at 6months postoperatively. One hundred and sixty patients (91 females for 69 males) with an average age of 23years [14-54] who underwent iMPFLR and had an evaluation scan at 6months postoperatively were evaluated with a mean follow-up of 97 ± 89months [12 to 166]. Functional International Knee Documentation Committee (IKDC) Score, Kujala score, and joint mobility were assessed preoperatively, at 6months and at the latest follow-up. The IKDC and Kujala scores were expressed as the difference between pre- and postoperative scores (dIKDC and dKujala). The position of the femoral tunnel was assessed according to the Schöttle criteria on post-operative radiographic profiles. Tunnel widening (at three levels of measurement) and the migration of the center of the tunnel were studied on a CT-scan analysis at 6months. Any correlation and regression between the evolution of the clinical scores and the measured scannographic parameters were investigated. The relationships between tunnel position and tunnel changes were also studied. Between pre- and post-op, the IKDC (45 ± 13 to 80 ± 15, p < 0.001) and Kujala (55 ± 11 to 87 ± 12, p < 0.001) scores were significantly improved. Patients with tunnel changes had decreased clinical and functional results at 6months post-op of an iMPFLR (p < 0.001). These changes in the femoral tunnel, evidenced by a tunnel entrance widening and migration of the tunnel center, were related to an initial malposition of the tunnel (p < 0.001). In iMPFLR, changes in the femoral tunnel, corresponding to dilatation and migration of the tunnel center, may occur. These changes are increased by the initial malpositioning of the femoral tunnel and are correlated with less good clinical and functional outcomes. Level IV.

Eccentrically widened bone tunnels after all-inside anterior cruciate ligament reconstruction: a computed tomography and three-dimensional model-based analysis

PurposeTo evaluate the extent of tunnel widening after anterior cruciate ligament reconstruction (ACLR) using the all-inside technique and to establish its correlation with patient-reported clinical outcomes and femoral graft bending angle (GBA).MethodsTunnel widening was evaluated using computed tomography (CT)-based three-dimensional (3D) models, and the femoral GBA was directly measured on CT images using the Picture Archiving and Communication System (PACS) software. Clinical follow-up was routine procedure, and patient-reported clinical outcomes mainly included International Knee Documentation Committee (IKDC), Lysholm, and Knee Injury and Osteoarthritis Outcome Scores (KOOS) scores, and subjective knee stability assessment.ResultsFifty-two patients received standard all-inside ACLR, with a median follow-up of 6 months. Reconstructed anterior cruciate ligaments (ACLs) were scanned during the first 3 days and 6 months after surgery. On both the femoral and tibial sides, bone tunnels were most significantly enlarged at the articular aperture segment; the femoral tunnel was 9.2 ± 1.3 mm postoperatively and was significantly enlarged by 32% to a mean tunnel diameter of 12.1 ± 2.0 mm at 6 months after surgery. Moreover, the extent of tunnel enlargement gradually decreased as the measured levels approached those of the bone cortex. The femoral tunnel center was shifted into the anterior and distal direction, and the tibial tunnel center was shifted into the posterior and lateral direction. Additionally, the mean femoral GBA was 105.9° ± 8.1° at the 6-month follow-up. Tunnel enlargement and GBA were not significantly correlated with patient-reported outcomes.ConclusionsFemoral and tibial tunnels were significantly greater and eccentrically shifted at the 6-month follow-up after all-side ACLR. However, the extent of tunnel widening does not markedly affect the short-term clinical outcomes. Meanwhile, the femoral GBA was not significantly correlated with femoral tunnel widening or patient-reported outcomes. Although the tunnel widening following all-inside ACLR was not associated with clinical outcomes, it potentially caused difficulties in revision ACLR.Level of evidenceLevel IV.

Revision Anterior Cruciate Ligament Reconstruction Using Bone Dowels

Background: Revision anterior cruciate ligament (ACL) reconstruction is technically challenging and may require the use of bone dowels in either 1 or 2 stages. Indications: The indications for bone dowels include tibial or femoral tunnel malposition or widening of the tunnels. In the patient case, the tibial tunnel aperture was positioned far medial to the native ACL insertion with a horizontal tunnel trajectory and the femoral tunnel was vertical. In addition, there was tunnel widening to 12 mm of both tibial and femoral tunnels. Technique Description: A bone-patellar tendon-bone autograft was harvested and diagnostic arthroscopy was performed. The previous tibial tunnel was sequentially reamed from 8 to 12 mm to adequately overdrill the previous widened tunnel. Next, the femoral tunnel was reamed to 12 mm in similar fashion. Using a tamp and guide pin, a 12 × 30-mm allograft bone dowel was then malleted into the femoral tunnel until it was flush with the medial aspect of the lateral femoral condyle. Another 12 × 30-mm bone dowel was then advanced into the tibial tunnel until it was just below the native articular margin. With the bone dowels securely in place, the ACL reconstruction using the harvested bone-patellar tendon-bone autograft was performed. Results: Werner et al reported a study of 12 patients who had excellent incorporation of femoral tunnel allograft bone dowels and comparable objective and subjective scoring to 2-stage techniques. Dragoo et al reported a study of 18 patients with tibial tunnel allograft bone dowels that demonstrated significant increases in patient-reported outcome measures and a significant decrease in tunnel widening. Discussion/Conclusion: Revision ACL reconstruction may require bone dowels if there are malpositioned tunnels or if there is tunnel widening. Overall, the literature demonstrates that 1-stage revision outcomes have been comparable to reported 2-stage revision outcomes, both of which are satisfactory.

Adjustable-Loop Cortical Suspensory Fixation Results in Greater Tibial Tunnel Widening Compared to Interference Screw Fixation in Primary Anterior Cruciate Ligament Reconstruction.

Background: Although the use of adjustable-loop suspensory fixation has increased in recent years, the influence of the shortcomings of suspensory fixation, such as the bungee-cord or windshield-wiper effects, on tunnel widening remains to be clarified. Hypothesis/Purpose: The purpose of this study was to compare adjustable-loop femoral cortical suspensory fixation and interference screw fixation in terms of tunnel widening and clinical outcomes after anterior cruciate ligament reconstruction (ACLR). We hypothesized that tunnel widening in the adjustable-loop femoral cortical suspensory fixation (AL) group would be comparable to that in the interference screw fixation (IF) group. Methods: This study evaluated patients who underwent primary ACLR at our institution between March 2015 and June 2019. The femoral and tibial tunnel diameters were measured using plain radiographs in the immediate postoperative period and 2 years after ACLR. Tunnel widening and clinical outcomes (Lysholm score, 2000 International Knee Documentation Committee subjective score, and Tegner activity level) were compared between the two groups. Results: There were 48 patients (mean age, 29.8 ± 12.0 years) in the AL group and 44 patients (mean age, 26.0 ± 9.5 years) in the IF group. Tunnel widening was significantly greater in the AL group than that in the IF group at the tibia anteroposterior (AP) middle (2.03 mm vs. 1.32 mm, p = 0.017), tibia AP distal (1.52 mm vs. 0.84 mm, p = 0.012), tibia lateral proximal (1.85 mm vs. 1.00 mm, p = 0.001), tibia lateral middle (2.36 mm vs. 1.03 mm, p < 0.001), and tibia lateral distal (2.34 mm vs. 0.85 mm, p < 0.001) levels. There were no significant differences between the two groups with respect to femoral tunnel widening and clinical outcomes. Conclusions: Tibial tunnel widening was significantly greater in the AL group than in the IF group at 2 years after primary ACLR. However, the clinical outcomes in the two groups were comparable at 2 years.

Comparing the Use of Flexible and Rigid Reaming Systems Through an Anteromedial Portal for Femoral Tunnel Creation During Anterior Cruciate Ligament Reconstruction: A Systematic Review.

Background:Recent studies have suggested that femoral tunnel drilling during anterior cruciate ligament (ACL) reconstruction (ACLR) with the use of a flexible reaming system through a standard anteromedial portal (AM-FR) may result in a different tunnel geometry compared with a rigid reamer through an accessory anteromedial portal with hyperflexion (AM-RR).Purpose:To summarize radiologic, anatomic, and clinical outcomes from available studies that directly compared the use of AM-FR versus AM-RR for independent femoral tunnel creation during ACLR.Study Design:Systematic review; Level of evidence, 4.Methods:A literature search was performed using the MEDLINE (PubMed) and Web of Science databases to identify all studies that directly compared radiologic, anatomic, and clinical outcomes between the use of AM-FR and AM-RR. The literature search, data recording, and methodological quality assessment was performed by 2 independent reviewers. The outcomes analyzed included resultant ACL graft positioning and graft bending angle; femoral tunnel positioning, aperture morphology, length, and widening; posterior wall breakage; and distance from various posterolateral knee structures.Results:A total of 13 studies met the eligibility criteria for inclusion. There was no difference in femoral tunnel aperture location between techniques. There were conflicting findings among studies regarding which technique resulted in a more acute graft bending angle. One study reported greater femoral tunnel widening upon follow-up with the use of AM-FR. AM-FR produced longer and more anteverted femoral tunnels than did AM-RR. The difference in tunnel length was significant and more prominent in lesser degrees of knee flexion. With AM-FR, femoral tunnels were farther from the lateral collateral ligament and peroneal nerve, and 1 of 5 studies had fewer reports of posterior wall breakage. There has been no literature comparing the clinical or functional outcomes of these techniques.Conclusion:Although no clinical studies exist comparing AM-FR and AM-RR for femoral tunnel creation during ACLR, both systems allow for reproducible positioning of an anatomic femoral tunnel aperture. The use of AM-FR results in longer and more anteverted femoral tunnels than using AM-RR, with exit points on the lateral femur that are different but safe. Surgeons should be aware of the technical differences with each method; however, further study is needed to identify any clinically important difference that results.

Comparison of Doubled Semitendinosus and Gracilis Autograft Versus Bone-Patellar Tendon-Bone Autograft for Reconstruction of the Anterior Cruciate Ligament

Background: The choice of graft for anterior cruciate ligament (ACL) reconstruction is a matter of debate with hamstring and bone-patellar tendon-bone being the most popular autologous graft options. Objective: The objective of this study was to conduct a prospective randomized control trial comparing doubled semitendinosus and gracilis graft versus bone-patellar tendon-bone graft. Materials and Methods: Sixty patients with chronic unilateral rupture of ACL underwent arthroscopically assisted ACL reconstruction using quadrupled hamstring and bone-tendon-bone graft after randomization. Both groups were comparable with demographic data, preoperative activity level, mechanism of injury, the interval between injury and operation, and preoperative laxity of the knee. The same well-proved surgical technique and aggressive rehabilitation were used in all cases. The outcome assessment was done using the visual analog scale, Lysholm score, Tegner activity level, and International Knee Documentation Committee (IKDC) evaluation system. Results: At 2-year follow-up, we found that results within the same groups showed statistically significant improvement as assessed by IKDC, Tegner’s, and Lysholm operative scores. There was also a significant correlation between the manual Lachman test and stress laxometry findings. There was no statistically significant difference between the scores of the two groups (hamstring and bone patella tendon). In the hamstring group, we recorded a higher incidence of femoral tunnel widening, and in the bone-patellar tendon-bone group the higher incidence of kneeling discomfort and increased area of decreased sensation in the skin. Conclusions: Arthroscopic ACL reconstruction by either hamstring tendon graft or bone-patellar tendon-bone graft gives equally satisfactory results.

Influence of femoral tunnel exit on the 3D graft bending angle in anterior cruciate ligament reconstruction

PurposeTo quantify the influence of the femoral tunnel exit (FTE) on the graft bending angle (GBA) and GBA-excursion throughout a full range of motion (ROM) in single-bundle anterior cruciate ligament (ACL) reconstruction.MethodsThree-dimensional (3D) surface models of five healthy knees were generated from a weight-bearing CT obtained throughout a full ROM (0, 30, 60, 90, 120°) and femoral and tibial ACL insertions were computed. The FTE was simulated for 16 predefined positions, referenced to the Blumensaat's line, for each patient throughout a full ROM (0, 30, 60, 90, 120°) resulting in a total of 400 simulations. 3D GBA was calculated between the 3D directional vector of the ACL and the femoral tunnel, while the intra-articular ACL insertions remained unchanged. For each simulation the 3D GBA, GBA-excursion, tunnel length and posterior tunnel blow-out were analysed.ResultsOverall, mean GBA decreased with increasing knee flexion for each FTE (p < 0.001). A more distal location of the FTE along the Blumensaat's line resulted in an increase of GBA and GBA-excursion of 8.5 ± 0.6° and 17.6 ± 1.1° /cm respectively (p < 0.001), while a more anterior location resulted in a change of GBA and GBA-excursion of -2.3 ± 0.6° /cm (+ 0.6 ± 0.4°/ cm from 0–60° flexion) and 9.8 ± 1.1 /cm respectively (p < 0.001).Mean tunnel length was 38.5 ± 5.2 mm (range 29.6–50.5). Posterior tunnel blow-out did not occur for any FTE.ConclusionAiming for a more proximal and posterior FTE, with respect to Blumensaat’s line, reliably reduces GBA and GBA-excursion, while preserving adequate tunnel length. This might aid to reduce excessive graft stress at the femoral tunnel aperture, decrease femoral tunnel widening and promote graft-healing.Level of EvidenceIV

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

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.

Inconsistencies in Reporting Risk Factors for Medial Patellofemoral Ligament Reconstruction Failure: A Systematic Review

Background: Medial patellofemoral ligament (MPFL) reconstruction is a common surgical treatment for patients with recurrent patellar instability. A variety of risk factors, such as age, trochlear dysplasia, patella alta, and increased tibial tubercle–trochlear groove (TT-TG) distance, have been identified and may lead to postoperative failure or poor outcomes. Purpose: While a large number of risk factors have been identified, significant heterogeneity exists in evaluating and reporting these risk factors in the literature. The goal of this study was to perform a systematic review to determine risk factors associated with worse outcomes after MPFL reconstruction and their consistency of being controlled for or analyzed among studies. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature was performed using the MEDLINE database to identify relevant clinical outcome studies after MPFL reconstruction for recurrent patellar instability. Eligible studies were evaluated for risk factors that were associated with MPFL failure, defined as recurrent instability or lack of improvement on patient-reported outcome (PRO) scores. Each study was then evaluated for inclusion of these risk factors. Results: Ten studies were included in the final analysis, comprising 1287 knees from 1275 patients who underwent isolated MPFL reconstruction. Of these 10 studies, 8 defined outcomes based on PROs and 3 defined outcomes based on postoperative recurrent instability (1 study included both outcomes). In the PRO failure group, 12 risk factors were found across all studies: trochlear dysplasia, trochlear bump height, elevated TT-TG, patellar tilt, hyperlaxity, age at first dislocation, age at surgery, body mass index, bilateral symptoms, WARPS/STAID score (weak atraumatic, risky anatomy, pain, and subluxation/strong, traumatic, anatomy normal, instability, and dislocation), femoral tunnel malposition, and femoral tunnel widening. In the recurrent instability failure group, 7 risk factors were found across all studies: trochlear dysplasia, bump height, patella alta, higher sulcus angle, higher congruence angle, preoperative J sign, and femoral tunnel malposition. Trochlear dysplasia and femoral tunnel malposition were consistently cited in several studies as risk factors for worse PROs and higher rates of recurrent instability. Patella alta was indicated as a significant risk factor for recurrent instability in 1 of 2 studies analyzing postoperative instability failures and was not associated with worse PROs in any of the studies analyzed. Similarly, elevated TT-TG distance was not a significant risk factor in any of the studies that analyzed recurrent instability as the failure endpoint. Conclusion: While various risk factors are postulated to affect outcomes after MPFL reconstruction, there remains inconsistency within the literature regarding the inclusion of all risk factors in a given analysis. Furthermore, the significance of these risk factors varies among studies in terms of whether they affect postoperative outcomes. We found that more severe trochlear dysplasia (types C and D) and femoral tunnel malposition (>10 mm from Schöttle’s point) appear to have the most consistent effect on producing higher rates of recurrent dislocation as well as worse PROs. Despite this, the role of concomitant bony procedures to adjust certain pathoanatomic risk factors in addition to MPFL reconstruction remains unknown. Future high-level studies must be conducted that respect the multifactorial nature of patellar instability and should analyze all risk factors (demographic, anatomic, and radiographic) reported to affect outcomes.