Tibial tunnel enlargement is affected by the tunnel diameter-screw ratio in tibial hybrid fixation for hamstring ACL reconstruction

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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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Most cited references 30

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Bone tunnel enlargement after anterior cruciate ligament reconstruction: fact or fiction?

J Höher, F Fu, Anne Kirstine H Møller (1997)

Radiographic enlargement of bone tunnels following anterior cruciate ligament (ACL) reconstruction has been recently introduced in the literature; however, the etiology and clinical relevance of this phenomenon remain unclear. While early reports suggested that bone tunnel enlargement is mainly the result of an immune response to allograft tissue, more recent studies imply that other biological as well as mechanical factors play a more important role. Biological factors associated with tunnel enlargement include foreign-body immune response (against allografts), non-specific inflammatory response (as in osteolysis around total joint implants), cell necrosis due to toxic products in the tunnel (ethylene oxide, metal), and heat necrosis as a response to drilling (natural course). Mechanical factors contributing to tunnel enlargement include stress deprivation of bone within the tunnel wall, graft-tunnel motion, improper tunnel placement, and aggressive rehabilitation. Graft-tunnel motion refers to longitudinal and transverse motion of the graft within the bone tunnel and can occur with various graft types and fixation techniques. Aggressive rehabilitation programmes may contribute to tunnel enlargement as the graft-bone interface is subjected to early stress before biological incorporation is complete. Further basic research is required to verify the effect of the various proposed factors on the etiology of bone tunnel enlargement. We recommend that routine follow-up examinations after ACL reconstruction should include the measurement of bone tunnel size in order to contribute to a better understanding of the incidence, time course, and clinical relevance of this phenomenon. Improved and more anatomical surgical fixation techniques may be useful for the prevention of bone tunnel enlargement.

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Tendon healing in a bone tunnel differs at the tunnel entrance versus the tunnel exit: an effect of graft-tunnel motion?

Kim Kawamura, Mu-Hyon Kim, Christian Dynybil … (2006)

Motion between a tendon graft and bone tunnel may impair graft incorporation and lead to tunnel widening. Healing of a tendon graft in a bone tunnel is inhibited by graft-tunnel motion. Controlled laboratory study. Anterior cruciate ligament reconstruction was performed in 5 cadaveric rabbit limbs, and 3-dimensional graft-tunnel motion was measured using micro-computed tomography. The authors then performed bilateral anterior cruciate ligament reconstruction in 15 rabbits and used histomorphometry to compare tendon-to-bone healing between the tunnel aperture, midtunnel, and tunnel exit and between the anterior and posterior aspects of the tunnel. Graft-tunnel motion was greatest at the tunnel apertures and least at the tunnel exit in cadaveric testing. Healing of the graft was slowest at the tunnel apertures. Tendon-bone interface width was greater at the aperture than at the tunnel exit for the femoral tunnel (P = .04). There was an inverse correlation between time zero graft-tunnel motion and healing in the femoral tunnel (P = .005). There was closer apposition of new bone to the tendon graft in the posterior half of the interface (P < .05). Osteoclasts were found at the tunnel apertures. Although graft-tunnel motion was only measured in cadaveric animals, results suggest that healing may be affected by the local mechanical environment, as graft healing in the femoral tunnel was inversely proportional to the magnitude of graft-tunnel motion. Graft-tunnel motion may impair early graft incorporation and may lead to osteoclast-mediated bone resorption, contributing to tunnel widening. Early, aggressive postoperative rehabilitation may have detrimental effects on graft-to-bone healing.

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Tunnel widening in anterior cruciate ligament reconstruction: a prospective evaluation of hamstring and patella tendon grafts.

J Bülow, Adam Bartlett, N M P Annear … (1998)

We report a prospective series evaluating the incidence and degree of tunnel widening in a well-matched series of patients receiving a hamstring or patella tendon graft for anterior cruciate ligament (ACL) deficiency. We correlated tunnel widening with clinical factors, knee scores, KT-1000 and isokinetic muscle strength to determine the clinical significance of this finding. Seventy-three patients at least 12 months post-ACL reconstruction were evaluated. Thirty-eight patients had received a doubled semitendinous and gracilis graft and 35 a bone-patella tendon-bone graft. All patients underwent a similar endoscopic procedure and accelerated postoperative rehabilitation. Tunnel widening was determined using standardized anteroposterior (AP) and lateral X-rays adjusted for magnification. A limited series of MRIs was performed to validate these measurements. There was a significant difference in the degree of tunnel widening between the two groups. The mean increase in femoral tunnel area in the hamstring group was 100.4% compared with a decrease of 25% in the patella tendon group (P = < 0.0001). In the tibial tunnel the mean increase in the hamstring group was 73.9% compared with a decrease of 2.1% in the patella tendon group (P = < 0.0001). The MRIs validated the plain film measurements. Tunnel widening did not correlate with the clinical findings, knee scores, KT-1000 or isokinetic muscle strength. Tunnel widening is marked in the hamstring group. Tunnel widening does not correlate with instability or a poor clinical outcome in the short term. The long-term implications of this finding are still to be determined.

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Author and article information

Contributors

Andreas Flury:

ORCID: http://orcid.org/0000-0003-0350-8101

andreas.flury@balgrist.ch

Journal

Journal ID (nlm-ta): Arch Orthop Trauma Surg

Journal ID (iso-abbrev): Arch Orthop Trauma Surg

Title: Archives of Orthopaedic and Trauma Surgery

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 0936-8051

ISSN (Electronic): 1434-3916

Publication date (Electronic): 14 March 2022

Publication date PMC-release: 14 March 2022

Publication date (Print): 2023

Volume: 143

Issue: 4

Pages: 1923-1930

Affiliations

GRID grid.7400.3, ISNI 0000 0004 1937 0650, Orthopaedic Department, , Balgrist University Hospital, University of Zurich, ; Forchstrasse 340, 8008 Zurich, Switzerland

Author information

Andreas Flury http://orcid.org/0000-0003-0350-8101

Article

Publisher ID: 4408

DOI: 10.1007/s00402-022-04408-2

PMC ID: 10030456

PubMed ID: 35287180

SO-VID: db1db9b5-d32a-4517-acf2-fcec2f9006b3

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

History

Date received : 10 January 2022

Date accepted : 27 February 2022

Funding

Funded by: University of Zurich

Open Access :

Open access funding provided by University of Zurich

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ScienceOpen disciplines: Orthopedics

Keywords: tunnel diameter,anterior cruciate ligament reconstruction,interference screw,hybrid fixation

Data availability:

ScienceOpen disciplines: Orthopedics

Keywords: tunnel diameter, anterior cruciate ligament reconstruction, interference screw, hybrid fixation

Tibial tunnel enlargement is affected by the tunnel diameter-screw ratio in tibial hybrid fixation for hamstring ACL reconstruction

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Introduction

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Conclusion

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Most cited references 30

Bone tunnel enlargement after anterior cruciate ligament reconstruction: fact or fiction?

Tendon healing in a bone tunnel differs at the tunnel entrance versus the tunnel exit: an effect of graft-tunnel motion?

Tunnel widening in anterior cruciate ligament reconstruction: a prospective evaluation of hamstring and patella tendon grafts.

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