Tibial Tunnel Enlargement is Affected by the Tunnel Diameter-screw Ratio in Tibial Hybrid Fixation for Hamstring ACL Reconstruction

Overview

Journal Arch Orthop Trauma Surg

Specialties Emergency Medicine
General Surgery
Orthopedics

Date 2022 Mar 14

PMID 35287180

Authors

Andreas Flury

Linda Wild

Manuel Waltenspul

Christoph Zindel

Lazaros Vlachopoulos

Florian B Imhoff

Sandro F Fucentese

Affiliations

Soon will be listed here.

Abstract

Introduction: There is no evidence on screw diameter with regards to tunnel size in anterior cruciate ligament reconstruction (ACLR) using hybrid fixation devices. The hypothesis was that an undersized tunnel coverage by the tibial screw leads to subsequent tunnel enlargement in ACLR in hybrid fixation technique.

Methods: In a retrospective case series, radiographs and clinical scores of 103 patients who underwent primary hamstring tendon ACLR with a hybrid fixation technique at the tibial site (interference screw and suspensory fixation) were obtained. Tunnel diameters in the frontal and sagittal planes were measured on radiographs 6 weeks and 12 months postoperatively. Tunnel enlargement of more than 10% between the two periods was defined as tunnel widening. Tunnel coverage ratio was calculated as the tunnel diameter covered by the screw in percentage.

Results: Overall, tunnel widening 12 months postoperatively was 23.1 ± 17.1% and 24.2 ± 18.2% in the frontal and sagittal plane, respectively. Linear regression analysis revealed the tunnel coverage ratio to be a negative predicting risk factor for tunnel widening (p = 0.001). The ROC curve analysis provided an ideal cut-off for tunnel enlargement of > 10% at a tunnel coverage ratio of 70% (sensitivity 60%, specificity 81%, AUC 75%, p < 0.001). Patients (n = 53/103) with a tunnel coverage ratio of < 70% showed significantly higher tibial tunnel enlargement of 15% in the frontal and sagittal planes. The binary logistic regression showed a significant OR of 6.9 (p = 0.02) for tunnel widening > 10% in the frontal plane if the tunnel coverage ratio was < 70% (sagittal plane: OR 14.7, p = 0.001). Clinical scores did not correlate to tunnel widening.

Conclusion: Tibial tunnel widening was affected by the tunnel diameter coverage ratio. To minimize the likelihood of disadvantageous tunnel expansion-which is of importance in case of revision surgery-an interference screw should not undercut the tunnel diameter by more than 1 mm.

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References

Webster K, Feller J, Hameister K . 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. 2001; 9(2):86-91. DOI: 10.1007/s001670100191. View

Petersen W, Forkel P, Achtnich A, Metzlaff S, Zantop T . Technique of anatomical footprint reconstruction of the ACL with oval tunnels and medial portal aimers. Arch Orthop Trauma Surg. 2013; 133(6):827-33. DOI: 10.1007/s00402-013-1741-6. View

Tajima T, Yamaguchi N, Nagasawa M, Morita Y, Nakamura Y, Chosa E . Early weight-bearing after anterior cruciate ligament reconstruction with hamstring grafts induce femoral bone tunnel enlargement: a prospective clinical and radiographic study. BMC Musculoskelet Disord. 2019; 20(1):274. PMC: 6547478. DOI: 10.1186/s12891-019-2653-6. View

Rodeo S, Kawamura S, Kim H, Dynybil C, Ying L . Tendon healing in a bone tunnel differs at the tunnel entrance versus the tunnel exit: an effect of graft-tunnel motion?. Am J Sports Med. 2006; 34(11):1790-800. DOI: 10.1177/0363546506290059. View

Kousa P, Jarvinen T, Vihavainen M, Kannus P, Jarvinen M . The fixation strength of six hamstring tendon graft fixation devices in anterior cruciate ligament reconstruction. Part II: tibial site. Am J Sports Med. 2003; 31(2):182-8. DOI: 10.1177/03635465030310020501. View

Kawaguchi Y, Kondo E, Kitamura N, Kai S, Inoue M, Yasuda K . Comparisons of femoral tunnel enlargement in 169 patients between single-bundle and anatomic double-bundle anterior cruciate ligament reconstructions with hamstring tendon grafts. Knee Surg Sports Traumatol Arthrosc. 2011; 19(8):1249-57. DOI: 10.1007/s00167-011-1455-7. View

Siebold R, Ellermann A . A prospective evaluation of tunnel enlargement in anterior cruciate ligament reconstruction with hamstrings: extracortical versus anatomical fixation. Knee Surg Sports Traumatol Arthrosc. 2002; 10(2):80-5. DOI: 10.1007/s00167-001-0267-6. View

Lee J, Otarodifard K, Jun B, McGarry M, Hatch 3rd G, Lee T . Is supplementary fixation necessary in anterior cruciate ligament reconstructions?. Am J Sports Med. 2011; 39(2):360-5. DOI: 10.1177/0363546510390434. View

Fink C, Zapp M, Benedetto K, Hackl W, Hoser C, Rieger M . Tibial tunnel enlargement following anterior cruciate ligament reconstruction with patellar tendon autograft. Arthroscopy. 2001; 17(2):138-43. DOI: 10.1053/jars.2001.21509. View

10.

Haberli J, Heilgemeir M, Valet S, Aiyangar A, Overes T, Henle P . Novel press-fit technique of patellar bone plug in anterior cruciate ligament reconstruction is comparable to interference screw fixation. Arch Orthop Trauma Surg. 2021; 142(8):1963-1970. DOI: 10.1007/s00402-021-04137-y. View

11.

Silva A, Sampaio R, Pinto E . Femoral tunnel enlargement after anatomic ACL reconstruction: a biological problem?. Knee Surg Sports Traumatol Arthrosc. 2010; 18(9):1189-94. DOI: 10.1007/s00167-010-1046-z. View

12.

Putnis S, Oshima T, Klasan A, Grasso S, Fritsch B, Coolican M . Adjustable suspension versus hybrid fixation in hamstring autograft anterior cruciate ligament reconstruction. Knee. 2020; 28:1-8. DOI: 10.1016/j.knee.2020.10.014. View

13.

Horstmann H, Petri M, Tegtbur U, Felmet G, Krettek C, Jagodzinski M . Quadriceps and hamstring tendon autografts in ACL reconstruction yield comparably good results in a prospective, randomized controlled trial. Arch Orthop Trauma Surg. 2021; 142(2):281-289. PMC: 8783919. DOI: 10.1007/s00402-021-03862-8. View

14.

White N, Borque K, Jones M, Williams A . Single-Stage Revision Anterior Cruciate Ligament Reconstruction: Experience With 91 Patients (40 Elite Athletes) Using an Algorithm. Am J Sports Med. 2020; 49(2):364-373. DOI: 10.1177/0363546520976633. View

15.

Hayback G, Raas C, Rosenberger R . Failure rates of common grafts used in ACL reconstructions: a systematic review of studies published in the last decade. Arch Orthop Trauma Surg. 2021; 142(11):3293-3299. PMC: 9522752. DOI: 10.1007/s00402-021-04147-w. View

16.

Wilson T, Kantaras A, Atay A, Johnson D . Tunnel enlargement after anterior cruciate ligament surgery. Am J Sports Med. 2004; 32(2):543-9. DOI: 10.1177/0363546504263151. View

17.

Tajima T, Chosa E, Kawahara K, Yamaguchi N . Prospective comparisons of femoral tunnel enlargement with 3 different postoperative immobilization periods after double-bundle anterior cruciate ligament reconstruction with hamstring grafts. Arthroscopy. 2014; 31(4):651-8. DOI: 10.1016/j.arthro.2014.10.015. View

18.

Taketomi S . Editorial Commentary: Tunnel Widening After Anterior Cruciate Ligament Reconstruction May Increase Laxity and Complicate Revision. Arthroscopy. 2021; 37(8):2564-2566. DOI: 10.1016/j.arthro.2021.04.013. View

19.

Chahla J, Dean C, Cram T, Civitarese D, OBrien L, Moulton S . Two-Stage Revision Anterior Cruciate Ligament Reconstruction: Bone Grafting Technique Using an Allograft Bone Matrix. Arthrosc Tech. 2016; 5(1):e189-95. PMC: 4886209. DOI: 10.1016/j.eats.2015.10.021. View

20.

Yoon K, Kim J, Park S, Park S . One-Stage Revision Anterior Cruciate Ligament Reconstruction: Results According to Preoperative Bone Tunnel Diameter: Five to Fifteen-Year Follow-up. J Bone Joint Surg Am. 2018; 100(12):993-1000. DOI: 10.2106/JBJS.17.01044. View