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

Can repair be an alternative to reconstruction in the management of acute anterior cruciate ligament rupture: A meta-analysis of randomized controlled trials

Purpose

To perform a meta-analysis to compare the clinical outcomes and failure rate of anterior cruciate ligament (ACL) repair and ACL reconstruction in acute ACL rupture.

Methods

Studies were searched on PubMed, Web of Science, and EMBASE for randomized controlled trials comparing ACL repair versus ACL reconstruction for ACL rupture. The bias risk was based on the Cochrane Handbook for Systematic Reviews of Interventions. Clinical outcomes included IKDC score, Lysholm score, Tegner score, anteroposterior (AP) knee laxity, and failure rate. The funnel plots were used to detect publication bias.

Results

Six randomized controlled study (RCTs) were included in this meta-analysis, involving a total of 478 patients. The mean follow-up varied from 1 to 5 years. The mean age of patients was between 17 and 29.1 years, the mean time from injury to surgery was 13-39 days. We found no statistical differences between ACL repair and ACLR in IKDC score (0.11; 95% CI, -0.17 to 0.40; p = 0.440; I 2 = 56.8%), Lysholm score (0.16; 95% CI, -0.10 to 0.42; p = 0.214; I 2 = 28.8%), Tegner score (0.05; 95% CI, -0.23 to 0.34; p = 0.719; I 2 = 0.0%), AP knee laxity (0.05; 95% CI, -0.17 to 0.27; p = 0.636; I 2 = 0.0%), and failure rate (RR, 1.10; 95% CI, 0.70-1.72; p = 0.695; I 2 = 27.3%).

Conclusion

ACL repair showed similar clinical outcomes compared with ACLR, and it could replace ACLR as an appropriate surgical method for acute proximal ACL rupture, but the indication and selection of patients are essential to be considered. Large numbers and more high-quality studies are still needed in the future to verify our results.

Level of Evidence

Level I.

Gradual stabilization and narrowing of bone tunnels following primary anterior cruciate ligament reconstruction

PURPOSE

The purpose of this study is to dynamically assess variations in tunnel diameters following anterior cruciate ligament reconstruction (ACLR) and investigate correlations with patient-reported outcomes (PROs) and graft maturity based on signal-to-noise quotient (SNQ).

METHODS

Tunnel diameter and tunnel position were measured using three-dimensional models derived from computed tomography (CT) data. Postoperative graft maturity and integration were evaluated using magnetic resonance imaging (MRI). Clinical outcomes were assessed through PROs, which included the International Knee Documentation Committee Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Scores and Lysholm scores. The correlation between tunnel enlargement extent, PROs and SNQ values, as well as correlations between confounding factors, tunnel diameter differences and SNQ were analyzed.

RESULTS

A total of 73 participants underwent primary ACLR and scheduled follow-ups. At the segment of the articular aperture, the femoral tunnel was enlarged by 32.3% to 10.4 ± 1.6 mm (p < 0.05), and the tibial tunnel was widened by 17.2% to 9.6 ± 1.2 mm (p < 0.05) at the 6-month follow-up. At 1 year postoperatively, diameters at the articular aperture were not further increased on the femoral (n.s.) and tibial (n.s.) sides. In early postoperative follow-up, the femoral tunnel was anteriorly and distally shifted, coupled with posterior and lateral deviation involving the tibial side, exhibiting minimal migration at 1-year follow-up. The degree of tunnel widening was not correlated with PROs and SNQ values. Age, gender, body mass index (BMI), time from surgery to follow-up, concomitant injuries and autograft type were not correlated with tunnel diameter differences and SNQ.

CONCLUSIONS

The femoral and tibial bone tunnels exhibited eccentrical widening and gradually stabilized at 1 year following ACLR. Furthermore, the enlarged bone tunnels were not correlated with unsatisfied PROs and inferior graft maturity.

LEVEL OF EVIDENCE

Level IV.

Arthroscopic Bone Grafting of Anterior Cruciate Ligament and Posterior Cruciate Ligament Tibial and Femoral Tunnels as a First-Stage Procedure

Recurrent multiligament knee injuries present unique challenges when performing revision ligament reconstructions. Bone tunnel widening is relatively common and considered a multifactorial condition that involves both biomechanical and biologic factors. When indicated, two-stage procedures ensure optimal revision reconstruction tunnel sizes and locations before ligament reconstruction and promote improved outcomes. Staged bone grafting is required when addressing significant tunnel widening and improper tunnel placement that puts graft incorporation at increased risk in ligament reconstructions of the knee. In this Technical Note, we describe the first stage of a two-stage procedure to address meniscus/chondral conditions, tunnel osteolysis from previous reconstructions, and tibial and femoral bone grafting for the anterior cruciate ligament and posterior cruciate ligament.

Inside-out tibial tunnel drilling technique is a reliable approach for all-inside ACL reconstruction: A longitudinal MRI assessment

Purpose

To longitudinally evaluate sockets localization, tunnel morphological changes and graft maturation after the inside-out tibial tunnel drilling technique for all-inside Anterior Cruciate Ligament Reconstruction (ACLR). We hypothesized that due the necessary angle for the inside-out reaming procedure, the described technique could input changes in the tibial socket.

Methods

Fourteen knees treated with the same all-inside ACLR technique were randomly assigned for a magnetic resonance evaluation. All patients were operated by the same surgeon and performed the same follow-up rehabilitation protocol. Socket's localization, shape and widening, as well as graft maturation and integration, were evaluated intraoperatively at 6 months and 4 years after surgery.

Results

Both femoral and tibial tunnels had an expected increase at 6 months follow-up. The widening was larger in the tibial tunnel (12.6 ± 10.0% vs. 9.1 ± 8.5%), yet this difference was not statistically different. Tibial tunnel was well centred in the tibial plateau and the integration of the graft was higher in the tibial socket. Four years after surgery, there was a general reduction of diameter in both tunnels. The tunnel occlusion rate was 33.3% for tibia and 16.7% for femur.

Conclusions

Overall, our results show that within a 4-year follow-up period, the inside-out tibial tunnel drilling technique for all-inside ACLR represents a safe technique that did not influence the tibial socket position nor tunnel widening or graft maturation in the long term.

Level of Evidence

Level IV.

Finite element analysis of anterior cruciate ligament reconstruction techniques: A comparison of the mechanical properties of all-inside fixation and traditional fixation

Objective

The main purpose of this study was to explore the mechanical properties of the anterior cruciate ligament and its attachments following reconstruction with the all-inside technique after anterior cruciate ligament injury.

Methods

Knee joint computed tomography data were collected from healthy volunteers, and knee joint models were created using Mimics software. A normal knee joint model, an all-inside reconstructed anterior cruciate ligament model, and a traditional reconstructed anterior cruciate ligament model were established. A tensile force of 134 N and a bending moment of 5 N/m were applied at the anterior aspect of the proximal tibia in these three models. The knee joint was subjected to external rotation, internal rotation, varus, valgus, flexion, and extension under this bending moment. The magnitude and distribution of stress on the ligament or graft and the magnitude and distribution of stress on the graft attachments were observed under different loading conditions.

Results

Under different external forces, the maximum stress on the ligament in the normal model fluctuated from 1.949 to 18.302 MPa, with an uncertain distribution of maximum stress. The maximum stress on the graft in the all-inside reconstructed anterior cruciate ligament model fluctuated from 0.705 to 3.465 MPa and was mainly distributed at the junction of the graft and the tibial footprint. In the traditional reconstructed anterior cruciate ligament model, the maximum stress on the graft fluctuated from 5.012 to 59.269 MPa and was primarily distributed at the junction of the interference screw and the graft. The concentration of stress on the loop and plate in the all-inside reconstructed anterior cruciate ligament model fluctuated from 70.461 to 346.363 MPa, with maximum stress distributed at the junction of the loop and the tibial surface. The maximum stress on the interference screw in the traditional reconstructed anterior cruciate ligament model fluctuated from 10.184 to 92.298 MPa, with maximum stress primarily distributed at the end of the interference screw.

Conclusion

Under different external forces, the graft used in all-inside anterior cruciate ligament reconstruction is subjected to fewer external forces than that used in traditional anterior cruciate ligament reconstruction, which may indicate a relatively stable mechanical environment. The strength of the loop and plate can theoretically tolerate daily knee joint movements of patients without injury.

All-Inside Anterior Cruciate Ligament Reconstruction Had Clinical Outcome Similar to the Transtibial Technique Except for Improved Side-to-Side Difference and Tegner Activity Scale: A Systematic Review and Meta-analysis

PURPOSE

To compare clinical outcomes of the all-inside technique with the transtibial technique in anterior cruciate ligament reconstruction based on available literature on this topic.

METHODS

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist, we conducted a systematic search for randomized controlled trials and cohort studies. Our comprehensive search encompassed PubMed, Embase, Cochrane Library, and Web of Science. We included randomized controlled trials (RCTs) and cohort studies that compared the 2 techniques with a minimal 1-year follow-up. Two independent authors assessed RCTs using the risk of bias tool developed by the Cochrane Collaboration and evaluated the quality of cohort studies using the Newcastle-Ottawa Scale for Assessing the Quality of Nonrandomized Comparative Trials. The subjective and objective outcomes, complications, and graft failure were obtained. R software was used to perform the analysis.

RESULTS

The present analysis enrolled 9 RCTs (n = 687) and 11 cohort studies (n = 910). After a minimal 1-year follow-up in RCTs, functional outcomes such as International Knee Documentation Committee (IKDC) subjective score, Lysholm score, Tegner activity scale, Knee Society Score, and hop test were found to be similar between 2 techniques. The laxity outcomes, including the IKDC objective grade and pivot-shift test, were suggested to be comparable. There was a significant difference favoring the transtibial technique in terms of side-to-side difference (P = .04; 95% confidence interval [CI], 0.08-0.90). The pooled data from cohort studies indicated equivalent results in terms of IKDC subjective score, Lysholm score, side-to-side difference, IKDC objective grade, complications, and graft failure, with the exception of statistical difference in the Tegner activity scale (P = .03; 95% CI, -0.50 to -0.04).

CONCLUSIONS

Our findings suggest that there is no difference in most outcome scores between the all-inside and transtibial techniques for anterior cruciate ligament reconstruction. There are statistically significant differences in side-to-side difference and Tegner activity scale favoring the all-inside technique.

LEVEL OF EVIDENCE

Level IV, meta-analysis of Level I to IV studies.

Acute anterior cruciate ligament rupture: can repair become an alternative to reconstruction: a meta-analysis of randomized controlled trials and cohort studies

PURPOSE

To perform a meta-analysis to compare clinical outcomes of anterior cruciate ligament (ACL) repair and ACL reconstruction for acute ACL rupture.

METHOD

We searched Pubmed, Embase, the Cochrane Library, and Web of Science databases to seek relevant studies. Clinical outcomes included failure rate, hardware removal rate, anteroposterior (AP) knee laxity, and patient-reported outcomes. In addition, subgroup analysis was carried out according to repair techniques, rupture locations, and study designs. Funnel plots were used to detect publication bias. All statistical analysis was performed using STATA (version 14.2, StataCorp).

RESULTS

A total of 10 articles were included in this study, comprising 5 randomized controlled trials (RCTs) and 5 cohort studies, involving a total of 549 patients. We found no statistical differences between the ACL repair and ACL reconstruction in the following outcomes: failure rate, AP knee laxity, International Knee Documentation Committee (IKDC) score, Lysholm score, Knee Injury and Osteoarthritis Outcome (KOOS) Score, and Tegner score. However, the ACL repair group had a higher hardware removal rate. Except for AP knee laxity results on different repair techniques, there was no statistical difference in other subgroup analyses.

CONCLUSION

Compared with ACL reconstruction, ACL repair shows similar results in clinical outcomes, and it is promising to be an effective alternative treatment for acute ACL rupture. Larger samples and higher-quality studies are needed to support our results and further explore the advantages of ACL repair in other aspects.

LEVEL OF EVIDENCE

Level III.

Anterior cruciate ligament femoral side retained stump technique reduces enlargement of the femoral bone tunnel after anterior cruciate ligament reconstruction

BACKGROUND

Enlargement of the bone tunnel has become an unavoidable early complication after anterior cruciate ligament (ACL) reconstruction, whether it is a single or double-bundle ACL reconstruction. Preservation of the ACL stump in ACL reconstruction reduces enlargement of the bone tunnel. The purpose of this study was to investigate the question of whether single-bundle ACL reconstruction using the ACL femoral side retained stump technique reduces enlargement of the femoral tunnel.

METHODS

Forty patients who underwent single-bundle reconstruction of the ACL were included in this study. The patients were categorized into a Remnant preservation group (Group R) and the Non-remnant preservation group (Group N). In the Remnant preservation group, a high-flexion femoral side retained stump technique was used intraoperatively for the establishment of the femoral side bone tunnel, and in the Non-remnant preservation group, the conventional femoral positioning method was used (we used a femoral positioning drill for localization and drilling of the femoral bone tunnel), and MRI of the operated knee joints was performed at 6 months postoperatively. We measured the internal diameter of the femoral bone tunnel at 5 mm from the intra-articular outlet of the femoral bone tunnel on an MRI scan image perpendicular to the femoral bone tunnel. The size of the tunnel was compared between the intraoperative drilling of the bone tunnel and the size of the bone tunnel at 6 months postoperatively. Postoperative clinical assessment was Lysholm score.

RESULTS

After a 6-month follow-up of 40 patients, the diameter of the femoral tunnel at a distance of 5 mm from the inner opening of the femoral tunnel was 10.96 ± 0.67 mm and 10.11 ± 0.62 mm in patients of group N and group R, respectively, and the difference was statistically significant (P < 0.05).The diameter of the femoral tunnel at 6 months postoperatively in group N and group R compared to the intraoperative bone tunnel increased by 2.58 ± 0.24 mm and 1.94 ± 0.31 mm, and the difference was statistically significant (P < 0.05).The femoral tunnel enlargement rates of group N and group R were 30.94 ± 3.00% and 24.02 ± 5.10%, respectively, and the differences were significant (P < 0.05).

CONCLUSION

ACL femoral side retained stump technique does not sacrifice the ideal location of the femoral tunnel and is able to preserve the possible benefits of the ACL stump: reduced femoral tunnel enlargement.

Outcomes of RigidFix Cross Pin Fixation in Femoral and Tibial Tunnel for Anterior Cruciate Ligament Reconstruction

OBJECTIVES

There is no clear consensus so far on which fixation method is most favorable for the tibial tunnel in anterior cruciate ligament reconstruction (ACLR). The purpose of this paper is to investigate the outcome of RigidFix cross pins fixation in the tibial tunnel and to explore the advantages of RigidFix applied both in the femoral and tibial tunnel with hamstring tendon graft in anterior cruciate ligament reconstruction.

METHODS

This retrospective study included 53 patients (male/female, 45/8) who underwent anterior cruciate ligament reconstruction using autologous hamstring tendons between January 2013 and December 2017 at our institute. The participants in group A (n = 36) received anterior cruciate ligament reconstruction with RigidFix cross pins fixation in both femoral and tibial tunnels, while those in group B (n = 17) with RigidFix cross pins fixation in the femoral tunnel and Interference screw fixation in the tibial tunnel. The visual analogue scale (VAS) score, International Knee Documentation Committee subjective knee form 2000 (IKDC2000) score, Lysholm knee scoring scale, Tegner activity score and the side-to-side difference were compared at 2 and 5 years postoperatively. The graft diameter, number of strands in graft and the average diameter of each strand were also compared between the two groups. The categorical parameters were analyzed by chi-square test and the continuous variables conforming to a normal distribution were analyzed by Student's t-test.

RESULTS

At 2 years postoperation, the VAS score (1.61 ± 0.55), side-to-side difference (1.50 ± 0.58) in group A were significantly lower than that in group B, and the IKDC2000 score (88.81 ± 3.88), Tegner activity score (6.14 ± 0.60) in group A were significantly higher than that in group B. At 5 years postoperation, the VAS score (1.64 ± 0.68), side-to-side difference (1.73 ± 0.63) in group A were significantly lower than that in group B, and the IKDC2000 score (89.09 ± 3.85), Tegner activity score (6.58 ± 0.94) in group A were slso significantly higher than that in group B. There was statistical difference in the change of the side-to-side difference between the two groups (group A vs. B, 0.22 ± 0.08 vs. 0.34 ± 0.11, p < 0.001). There were also statistical differences in the graft diameter (group A vs. B, 7.83 ± 0.74 vs. 7.41 ± 0.51, p = 0,038), number of strands in graft (5.67 ± 0.72 vs. 4.00 ± 0.00, p < 0.001) and the average diameter of each strand (1.41 ± 0.22 vs. 1.85 ± 0.13, p < 0.001) between the two groups.

CONCLUSION

RigidFix cross pins fixation in the tibial tunnel for anterior cruciate ligament reconstruction can achieve better 5-year results when compared with the interference screw, and the hamstring tendon can be folded into a thicker graft when RigidFix cross pins were applied in both femoral and tibial tunnels.

Application of multiplanar reconstruction and 3D printing in anterior cruciate ligament revision

OBJECTIVES

Anterior cruciate ligament injury is the most common type of knee joint ligament injury. Anterior cruciate ligament reconstruction has a high failure rate, with bone tunnel abnormalities as the most significant factor in these failures. Digital orthopedic technology can effectively develop implementation plans for the revision, thus increasing the success rate. This study aims to develop a surgical plan for anterior cruciate ligament revision by employing multiplanar reconstruction (MPR) for measuring bone tunnel position and diameter, and simulating bone tunnel creation via 3D printing preoperatively.

METHODS

A total of 12 patients who underwent anterior cruciate ligament revision at the Third Xiangya Hospital of Central South University between 2014 and 2021 were retrospectively studied. The data included patient demographics, preoperative formulated knee joint 3D printing models, and preoperative knee CT scans. The study measured the bone tunnel's diameter and position to guide the establishment of revision bone tunnels during surgery, reassessed the postoperative bone tunnels, and evaluated knee joint functional scores [including International Knee Documentation Committee Knee Evaluation Form (IKDC) score, Lysholm score, and Tegner exercise level score].

RESULTS

Preoperative measurements revealed suboptimal femoral tunnels positions in 4 patients and tibial tunnels positions in 2 patients. MPR and 3D printing technology were used to guide the establishment of a new bone canal during surgery, and postoperative measurements were satisfactory for all patients. Preoperative measurements demonstrated the interclass correlation coefficient for femoral tunnels and tibial tunnels diameters were 0.843 (P<0.05) and 0.889 (P<0.001), respectively. Meanwhile, the intraclass correlation coefficient were 0.811 (P<0.05) and 0.784 (P<0.05), respectively. The intraoperative diameter of femoral and tibial tunnels showed excellent correlation with postoperative CT measurements, with intraclass correlation coefficient values of 0.995 (P<0.001) and 0.987 (P<0.001), respectively. All bone tunnel positions were within the normal range. At the final follow-up, knee joint function scores in all 12 patients improved significantly compared to pre-surgery (P<0.001), and the reoperation rate was zero.

CONCLUSIONS

MPR and 3D printing technology can accurately measure the parameters of reconstructed anterior cruciate ligament bone tunnels. Personalized revision plans for patients with reconstruction failure enhances the success rate of revision surgery and improves patient prognosis.

Tunnel widening after ACL reconstruction with different fixation techniques: aperture fixation with biodegradable interference screws versus all-inside technique with suspensory cortical buttons. 5-year data from a prospective randomized trial

BACKGROUND

The aim of the present study was to examine tunnel widening and clinical outcomes after anterior cruciate ligament reconstruction (ACLR) using two different fixation methods: aperture fixation with biodegradable interference screws versus all-inside ACLR with suspensory cortical buttons.

METHODS

Tunnel widening was assessed using volumetric and diameter measurements on magnetic resonance imaging (MRI) scans directly after surgery, as well as 6 months and 2 and 5 years postoperatively. Clinical outcomes were assessed after 5 years with instrumented tibial anteroposterior translation measurement (KT-1000), single-leg hop testing, and the IKDC, Lysholm, and Tegner activity scores.

RESULTS

At the final follow-up, the study population consisted of 21 patients, 12 of whom underwent screw fixation and 9 of whom had button fixation. 3 patients with all-inside ACLR had sustained early repeat ruptures within 6 months after surgery and had to be excluded from the further analysis. With screw fixation, the tibial tunnel volume changed significantly more over time compared to all-inside button fixation, with a larger initial increase at 6 months (from postoperative 2.9 ± 0.2 to 3.3 ± 0.2 cm3 at 6 months versus 1.7 ± 0.1 to 1.9 ± 0.2 cm3) and a greater final decrease over 2-5 years postoperatively (from 3.1 ± 0.2 to 1.9 ± 0.2 cm3 versus 1.8 ± 0.2 ± 0.1 to 1.3 ± 0.1 cm3) (P < 0.001). The femoral tunnel volume remained comparable between the two groups throughout the follow-up period, with an initial 1.6 ± 0.1 cm3 in both groups and 1.2 ± 0.1 vs. 1.3 ± 0.1 after 5 years in the screw and button groups, respectively (P ≥ 0.314). The maximum tibial and femoral tunnel diameters were significantly larger with screw fixation at all four time points. Tibial diameters measured 11.1 ± 0.2, 12.3 ± 0.3, 12.3 ± 0.4, and 11.2 ± 0.4 mm in the screw group versus 8.1 ± 0.3, 8.9 ± 0.3, 9.1 ± 0.4 and 8.2 ± 0.5 mm in the button group (P < 0.001). Femoral diameters measured 8.6 ± 0.2, 10.5 ± 0.4, 10.2 ± 0.3, and 8.9 ± 0.3 versus 7.3 ± 0.3, 8.4 ± 0.4, 8.4 ± 0.3, 7.5 ± 0.3, respectively (P ≤ 0.007). Four patients (33%) in the screw group exceeded a diameter of 12 mm on the tibial side after 5 years versus none in the button group (not significant, P = 0.104). Tibial anteroposterior translation measurement with KT-1000 after 5 years was 2.3 ± 2.4 mm in the screw group versus 3.2 ± 3.5 mm in the button group (not significant, P = 0.602). There were no significant differences between the groups in any of the other clinical outcomes.

CONCLUSION

Tibial tunnels in ACLR with screw fixation were associated with a larger increase in tunnel volume within the first 2 years and a greater decrease up to 5 years after surgery, while femoral tunnel volumes did not differ significantly. On the tibial side, the need for staged revision ACLR may be greater after biodegradable interference screw fixation if repeat ruptures occur, especially within the first 2 years after primary ACLR. Concerns may remain regarding a higher graft failure rate with all-inside ACLR.

LEVEL OF EVIDENCE

II.

RCT CONSORT

NCT01755819.

Anterior Screw Insertion Results in Greater Tibial Tunnel Enlargement Rates after Single-Bundle Anterior Cruciate Ligament Reconstruction than Posterior Insertion: A Retrospective Study

Background and Objectives: Tunnel enlargement (TE) is a widely reported phenomenon after anterior cruciate ligament reconstruction (ACLR). Given the paucity of knowledge in the literature, it remains unclear whether screw position in the tunnel affects TE. This retrospective cohort study evaluated differences in postoperative tunnel enlargement rates (TER) and clinical results between anterior and posterior tibial interference screw insertion during single-bundle ACLR using autologous hamstring grafts. Materials and Methods: A group of consecutive patients that underwent primary arthroscopic single-bundle ACLR in our hospital were screened and divided into two groups based on the position of the tibial interference screw (determined by Computer Tomography within 3 days after surgery): anterior screw position group (A) and posterior screw position group (B). The bone tunnel size was measured using magnetic resonance imaging (MRI) performed 1 year after surgery. International Knee Documentation Committee (IKDC) score and the Knee Injury and Osteoarthritis Outcome Score (KOOS) were used for clinical results 1 year postoperatively. Results: 87 patients were included. The TER of Group A is higher than that of Group B (43.17% vs. 33.80%, p = 0.024). Group A showed a significant increase (12.1%) in enlargement rates at the joint line level than group B (43.77% vs. 31.67%, p = 0.004). Moreover, KOOS and IKDC scores improved in both groups. There were no significant differences in clinical outcomes between the two groups. Conclusions: One year after ACLR, patients with posterior screw showed significantly lower TE than patients with anterior screw. However, the position of screw did not lead to differences in clinical results over our follow-up period. Posterior screw position in the tibial tunnel maybe a better choice in terms of reducing TE. Whether the different screw positions affect the long-term TE and long-term clinical outcomes needs to be confirmed by further studies.