|Year : 2023 | Volume
| Issue : 1 | Page : 62-65
Clinical effect of morphological changes in bone tunnels after anterior cruciate ligament reconstruction
Abhijeet Subhash, Nishant Kashyap, Indrajeet Kumar, Ritesh Runu
Department of Orthopedics, IGIMS Patna, Bihar, India
|Date of Submission||29-Jun-2022|
|Date of Decision||30-Jun-2022|
|Date of Acceptance||30-Jun-2022|
|Date of Web Publication||27-Dec-2022|
Department of Orthopedics, IGIMS Patna-14, Bihar
Source of Support: None, Conflict of Interest: None
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.
Keywords: Anterior cruciate ligament reconstruction, clinical outcome, tunnel widening
|How to cite this article:|
Subhash A, Kashyap N, Kumar I, Runu R. Clinical effect of morphological changes in bone tunnels after anterior cruciate ligament reconstruction. J Orthop Dis Traumatol 2023;6:62-5
|How to cite this URL:|
Subhash A, Kashyap N, Kumar I, Runu R. Clinical effect of morphological changes in bone tunnels after anterior cruciate ligament reconstruction. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jan 30];6:62-5. Available from: https://jodt.org/text.asp?2023/6/1/62/365284
| Introduction|| |
Anterior cruciate ligament (ACL) reconstruction is among the most performed orthopedics knee surgery. Regardless of the technique used, tunnel enlargement has been reported among the related complications by authors.,,,, Mostly, it occurs within 6 months postoperatively and remains static till 1 year, but in some cases, it may continue up to 2 years and it has been reported with all types of grafts which may be autograft or allograft (bone-patellar bone graft or hamstring graft). Biomechanical factors that primarily contribute to tunnel widening are tunnel position along with types and rigidity of fixations (cortical or metaphyseal). The biological factors such as synovial fluid spillage at the bone and soft-tissue graft interface, poor bone quality, and disintegration of the bioabsorbable screw May cause tunnel widening. Previous studies on tunnel enlargement associate them with anterior knee laxity, graft failure,, and risk of staged revision surgery. On the contrary, many studies have proved that tunnel widening does not affect the clinical outcome following ACL reconstruction (ACL-R).,,, Computed tomography (CT) is shown to be a reliable imaging modality for the morphological evaluation of tunnels. As tunnel enlargement occurs in multiple directions, three-dimensional (3D) reconstruction of the CT image enables a more accurate evaluation. In addition, multi-planar analysis using 3D reconstructed CT images enables a more accurate evaluation because tunnel enlargement occurs in multiple directions.
Thus, the purpose of this study was a morphological evaluation of tunnels after 1 year of ACL-R using a hamstring tendon graft and to investigate any significant correlation between clinical scores and any such tunnel enlargement.
| Materials and Methods|| |
This was a prospective study conducted from February 2020 to May 2022 at a tertiary care hospital after institutional ethical clearance vide letter no. 747/IEC/2019/IGIMS. All patients with an ACL injury who underwent primary arthroscopic ACL-R using hamstring tendon autograft and were more than 18 years of age were included in the study after informed written consent. Patients with associated medial or lateral collateral ligament injury or those undergoing revision ACL-R and <18 years of age were excluded from the study. Diagnosis of ACL tear was made by clinical examination using Lachman and pivot shift tests and confirmed with MRI. Preoperative clinical evaluation of knee function and stability was performed using the Lysholm knee score and Tegner activity level.
Under spinal anesthesia, an arthroscopic examination was done to confirm ACL tear, and then, an ipsilateral autologous hamstring graft was harvested and prepared. The final thickness of the femoral and tibial ends was noted, and the femoral and tibial tunnels were made in accordance with it. The graft was fixed to the femoral tunnel by cortical fixation and to the tibial tunnel by interference screw and suture post (i.e., hybrid fixation). The diameters of the tibial and femoral tunnels after reaming were noted. Standard postoperative rehabilitation included postoperative limited mobilization in a hinged knee brace for 2 weeks.
At the end of a year after the operative intervention, clinical evaluation of knee function and stability was performed in a similar fashion as of preoperative. CT scan measurements of the femoral and tibial tunnels were done [Figure 1], [Figure 2], [Figure 3]. Transosseous tibial tunnel diameter was measured at four levels: axial section (T1) (T3) and sagittal section (T2) (T4) at plateau and midpoint. Femoral tunnel measurements were also done at four points: the axial (F1) and coronal (F2) sections in the middle of the tunnel and the axial sections at the notch (F3) and the end of the tunnel (F4).
|Figure 1: Coronal section of femoral tunnel showing conical enlargement and its measurement|
Click here to view
The statistical analysis was done using SPSS version 21.0 software SPSS (IBM, USA). The widening of the tibial and femoral tunnels at 12 months of follow-up was evaluated and correlated with different clinical scores. The Pearson correlation coefficient was used to identify the relationship between femoral and tibial tunnel widening and quantitative clinical parameters. P < 0.05 was considered statistically significant.
| Results|| |
This study included 55 patients with a mean age of 32 years (19–48 years), who underwent ACL-R surgery between February 2020 and May 2022, out of which 49 were males and 6 were females. There were 29 right and 26 left knees.
At 1 year, the typical appearance of the femoral tunnel widening was typical in a conical shape with a mean increase in the tunnel diameter of 1.41 + 0.4 mm (17.1%). In F1, the mean tunnel diameter was 8.95 + 0.04 which is an increase of 11.7%. In F2, the mean tunnel diameter was 9.66 + 0.05 mm which is an increase of 16.9%. In F3, the mean tunnel diameter was 11.15 + 0.04 mm which is an increase of 24.6%. In F4, the mean tunnel diameter was 9.76 + 0.07 mm which is an increase of 15.2% [Table 1].
The 3D appearance of the tibial tunnel is cylindrical, with a mean increase in tunnel diameter of 2.05 + 0.03 (22.74%). In T1, the mean tunnel diameter was 11.22 + 0.04 which is an increase of 18.4%. In T2, the mean tunnel diameter was 12.39 + 0.05 mm which is an increase of 21.6%. In T3, the mean tunnel diameter was 12.56 + 0.04 mm which is an increase of 24.8%. In T4, the mean tunnel diameter was 13.43 + 0.07 mm which is an increase of 25.4% [Table 2].
The mean Lysholm score increased from 55.7 ± 16 (52–77) points preoperatively to 94.8 ± 18 points (89–100) postoperatively. The mean Tegner activity score increased from 2.5 ± 0.96 points preoperatively to 5.4 ± 1.05 postoperatively [Table 3].
There was no re-trauma or iterative rupture at the last follow-up. Radiographic findings did not demonstrate any tunnel malposition, and CT scan analysis did not show a greater tunnel widening compared with other studies. There was no significant correlation between tunnel enlargement and the clinical outcome.
| Discussion|| |
The main purpose of the present retrospective clinical study was to evaluate the impact of femoral and tibial tunnel widening after ACL-R on clinical outcomes after a 1-year follow-up.
Regardless of the technique used bone tunnels created for graft placement in ACL-R enlarge with time. Jansson et al. report an average femoral and tibial tunnel enlargement on AP-view of plain X-ray of 33% and 23%, respectively, while Fules et al. reports an average tibial tunnel enlargement of 33% on magnetic resonance imaging, after ACL-R using a hamstring graft. The present study demonstrates a 17.9% increment in femoral tunnel diameter and a 22.6% increment in tibial tunnel diameter following ACL-R with hamstring grafts.
Some studies have correlated the relationship between tunnel widening and rehabilitation. Murty et al. showed that immobilization for 2 weeks was associated with increased tunnel enlargement. L'Insalata et al. show that less aggressive rehabilitation may reduce the micromotion of the graft in the tibial and femoral tunnels, thus reducing the “synovial bathing effect” and the nonspecific inflammatory response. In this study, a less aggressive rehabilitation process resulted in an acceptable rate of tunnel enlargement.
In a review article, Höher et al. discuss theoretical concepts surrounding the etiology as well as possible measures for preventing bone tunnel enlargement. They conclude that prevention of bone tunnel enlargement may be achieved by a more anatomical initial graft fixation. Moreover, this is also backed by the findings of Schulte et al., who found that tunnel expansion was greater in the lateral radiograph for bone-patellar tendon-bone grafts fixed more distally in the tibial tunnel. In our study, we created anatomic tunnel hence -- in comparison with other studies with nonanatomic tunnel creation, the percentage of tunnel widening is considerably less.
The limitations of our study was short term follow up of 1 year. CT scan measurement need to be evaluated for interobserver variability.
| Conclusions|| |
The present study demonstrated that femoral and tibial tunnel enlargement is a regular phenomenon after anatomic ACL-R using hamstring tendon autografts. The tunnel enlargement does not affect the clinical outcome during the 1-year period after anatomic ACL reconstruction.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]