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Stress distribution is deviated around the aperture of the femoral tunnel in the anatomic anterior cruciate ligament reconstruction

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Final tunnel location in the anterior cruciate ligament (ACL) reconstruction is unpredictable due to tunnel widening and/or transposition. The mechanical stress around the tunnel aperture seems to be a major factor but is not fully investigated. The purpose of this study was to measure the stress from the ACL graft around the tunnel aperture when the ACL graft tension reaches its peak.

Methods

Six cadaveric knees were used. Single-bundle ACL reconstruction was performed using a hamstrings graft. Both femoral and tibial tunnels were created at the centre of the original ACL footprint. A 7-mm-internal-diameter aluminium cylinder with pressure sensors was placed in the femoral tunnel. Hamstrings graft with a microtension sensor was inserted. After fixation, passive extension-flexion was performed while monitoring the tunnel aperture pressure and the graft tension simultaneously. The pressure on the femoral tunnel aperture when the ACL graft tension reach its peak was compared between four directions.

Results

The ACL graft tension peaked (67 ± 49 N) at full extension (−5.8 ± 4.1°). Pressure at the femoral tunnel aperture was different between different directions (p < 0.01). Distal part had significantly larger pressure (1.7 ± 1.3 MPa) than the other directions (p < 0.01). Second largest pressure was carried in the anterior part (0.6 ± 0.5 MPa), followed by proximal and posterior parts (0.4 ± 0.3, 0.2 ± 0.2 MPa respectively).

Conclusion

The stress distribution at the femoral tunnel aperture is not equal in different directions, while the distal part dominantly bears the stress from the ACL graft. Surgeons should pay close attention to the distal edge of the femoral tunnel which should be inside the anatomic ACL footprint eventually.

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References

  1. Araki D, Kuroda R, Kubo S, Fujita N, Tei K, Nishimoto K, Hoshino Y, Matsushita T, Matsumoto T, Nagamune K, Kurosaka M (2011) A prospective randomised study of anatomical single-bundle versus double-bundle anterior cruciate ligament reconstruction: quantitative evaluation using an electromagnetic measurement system. Int Orthop 35(3):439–446

    Article  PubMed  Google Scholar 

  2. Araki D, Kuroda R, Matsumoto T, Nagamune K, Matsushita T, Hoshino Y, Oka S, Nishizawa Y, Kurosaka M (2014) Three-dimensional analysis of bone tunnel changes after anatomic double-bundle anterior cruciate ligament reconstruction using multidetector-row computed tomography. Am J Sports Med 42(9):2234–2241

    Article  PubMed  Google Scholar 

  3. Baumfeld JA, Diduch DR, Rubino LJ, Hart JA, Miller MD, Barr MS, Hart JM (2008) Tunnel widening following anterior cruciate ligament reconstruction using hamstring autograft: a comparison between double cross-pin and suspensory graft fixation. Knee Surg Sports Traumatol Arthrosc 16(12):1108–1113

    Article  PubMed  Google Scholar 

  4. Brophy RH, Voos JE, Shannon FJ, Granchi CC, Wickiewicz TL, Warren RF, Pearle AD (2008) Changes in the length of virtual anterior cruciate ligament fibers during stability testing: a comparison of conventional single-bundle reconstruction and native anterior cruciate ligament. Am J Sports Med 36(11):2196–2203

    Article  PubMed  Google Scholar 

  5. Cha PS, Brucker PU, West RV, Zelle BA, Yagi M, Kurosaka M, Fu FH (2005) Arthroscopic double-bundle anterior cruciate ligament reconstruction: an anatomic approach. Arthroscopy 21:1275

    Article  PubMed  Google Scholar 

  6. Chechik O, Amar E, Khashan M, Lador R, Eyal G, Gold A (2013) An international survey on anterior cruciate ligament reconstruction practices. Int Orthop 37(2):201–206

    Article  PubMed  Google Scholar 

  7. Clatworthy MG, Annear P, Bulow JU, Bartlett RJ (1999) Tunnel widening in anterior cruciate ligament reconstruction: a prospective evaluation of hamstring and patellar tendon grafts. Knee Surg Sports Traumatol Arthrosc 7(3):138–145

    Article  CAS  PubMed  Google Scholar 

  8. Desai N, Alentorn-Geli E, van Eck CF, Musahl V, Fu FH, Karlsson J, Samuelsson K (2016) A systematic review of single- versus double-bundle ACL reconstruction using the anatomic anterior cruciate ligament reconstruction scoring checklist. Knee Surg Sports Traumatol Arthrosc 24(3):862–872

    Article  PubMed  Google Scholar 

  9. Fahey M, Indelicato PA (1994) Bone tunnel enlargement after anterior cruciate ligament replacement. Am J Sports Med 22(3):410–414

    Article  CAS  PubMed  Google Scholar 

  10. Fujii M, Sasaki Y, Araki D, Furumatsu T, Miyazawa S, Ozaki T, Linde-Rosen M, Smolinski P, Fu FH (2016) Evaluation of the semitendinosus tendon graft shift in the bone tunnel: an experimental study. Knee Surg Sports Traumatol Arthrosc 24(9):2773–2777

    Article  PubMed  Google Scholar 

  11. Fujita N, Kuroda R, Matsumoto T, Yamaguchi M, Yagi M, Matsumoto A, Kubo S, Matsushita T, Hoshino Y, Nishimoto K, Araki D, Kurosaka M (2011) Comparison of the clinical outcome of double-bundle, anteromedial single-bundle, and posterolateral single-bundle anterior cruciate ligament reconstruction using hamstring tendon graft with minimum 2-year follow-up. Arthroscopy 27:906–913

    Article  PubMed  Google Scholar 

  12. Giron F, Cuomo P, Aglietti P, Bull AM, Amis AA (2006) Femoral attachment of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 14(3):250–256

    Article  PubMed  Google Scholar 

  13. Harner CD, Marks PH, Fu FH, Irrgang JJ, Silby MB, Mengato R (1994) Anterior cruciate ligament reconstruction: endoscopic versus two-incision technique. Arthroscopy 10(5):502–512

    Article  CAS  PubMed  Google Scholar 

  14. Hoher J, Livesay GA, Ma CB, Withrow JD, Fu FH, Woo SL (1999) Hamstring graft motion in the femoral bone tunnel when using titanium button/polyester tape fixation. Knee Surg Sports Traumatol Arthrosc 7(4):215–219

    Article  CAS  PubMed  Google Scholar 

  15. Hoshino Y, Kuroda R, Nagamune K, Nishimoto K, Yagi M, Mizuno K, Yoshiya S, Kurosaka M (2007) The effect of graft tensioning in anatomic 2-bundle ACL reconstruction on knee joint kinematics. Knee Surg Sports Traumatol Arthrosc 15(5):508–514

    Article  PubMed  Google Scholar 

  16. Hoshino Y, Nagamune K, Yagi M, Araki D, Nishimoto K, Kubo S, Minoru D, Kurosaka M, Kuroda R (2009) The effect of intra-operative knee flexion angle on determination of graft location in the anatomic double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 17(9):1052–1060

    Article  PubMed  Google Scholar 

  17. Hutchinson MR, Ash SA (2003) Resident’s ridge: assessing the cortical thickness of the lateral wall and roof of the intercondylar notch. Arthroscopy 19(9):931–935

    Article  PubMed  Google Scholar 

  18. Iorio R, Vadalà A, Di Vavo I, De Carli A, Conteduca F, Argento G, Ferretti A (2008) Tunnel enlargement after anterior cruciate ligament reconstruction in patients with post-operative septic arthritis. Knee Surg Sports Traumatol Arthrosc 16(10):921–927

    Article  CAS  PubMed  Google Scholar 

  19. Jagodzinski M, Foerstemann T, Mall G, Krettek C, Bosch U, Paessler HH (2005) Analysis of forces of ACL reconstructions at the tunnel entrance: is tunnel enlargement a biomechanical problem? J Biomech 38(1):23–31

    Article  CAS  PubMed  Google Scholar 

  20. Jansson KA, Harilainen A, Sandelin J, Karjalainen PT, Aronen HJ, Tallroth K (1999) Bone tunnel enlargement after anterior cruciate ligament reconstruction with the hamstring autograft and EndoButton fixation technique. A clinical, radiographic and magnetic resonance imaging study with 2 year follow-up. Knee Surg Sports Traumatol Arthrosc 7:290–295

    Article  CAS  PubMed  Google Scholar 

  21. Jarvela T, Moisala AS, Paakkala T, Paakkala A (2008) Tunnel enlargement after double-bundle anterior cruciate ligament reconstruction: a prospective, randomized study. Arthroscopy 24(12):1349–1357

    Article  PubMed  Google Scholar 

  22. Kamath GV, Redfern JC, Greis PE, Burks RT (2011) Revision anterior cruciate ligament reconstruction. Am J Sports Med 39(1):199–217

    Article  PubMed  Google Scholar 

  23. Karlsson J, Irrgang JJ, van Eck CF, Samuelsson K, Mejia HA, Fu FH (2011) Anatomic single- and double-bundle anterior cruciate ligament reconstruction, part 2: clinical application of surgical technique. Am J Sports Med 39(9):2016–2026

    Article  PubMed  Google Scholar 

  24. Kawaguchi S, Nagamune K, Nishizawa Y, Oka S, Araki D, Hoshino Y, Matsushita T, Kuroda R, Kurosaka M (2015) A comparison of ligament tensions between intra- and extra-articular measurement in anterior cruciate ligament reconstruction. JACIII 19:778–784

    Article  Google Scholar 

  25. Klein JP, Lintner DM, Downs D, Vavrenka K (2003) The incidence and significance of femoral tunnel widening after quadrupled hamstring anterior cruciate ligament reconstruction using femoral cross pin fixation. Arthroscopy 19(5):470–476

    Article  PubMed  Google Scholar 

  26. Kocher MS, Steadman JR, Briggs KK, Sterett WI, Hawkins RJ (2004) Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction. Am J Sports Med 32(3):629–634

    Article  PubMed  Google Scholar 

  27. Koga H, Nakamae A, Shima Y, Iwasa J, Myklebust G, Engebretsen L, Bahr R, Krosshaug T (2010) Mechanisms for noncontact anterior cruciate ligament injuries: knee joint kinematics in 10 injury situations from female team handball and basketball. Am J Sports Med 38(11):2218–2225

    Article  PubMed  Google Scholar 

  28. L’Insalata JC, Klatt B, Fu FH, Harner CD (1997) Tunnel expansion following anterior cruciate ligament reconstruction: a comparison of hamstring and patellar tendon autografts. Knee Surg Sports Traumatol Arthrosc 5:234–238

    Article  PubMed  Google Scholar 

  29. Middleton KK, Hamilton T, Irrgang JJ, Karlsson J, Harner CD, Fu FH (2014) Anatomic anterior cruciate ligament (ACL) reconstruction: a global perspective. Part 1. Knee Surg Sports Traumatol Arthrosc 22(7):1467–1482

    Article  CAS  PubMed  Google Scholar 

  30. Nishimoto K, Kuroda R, Mizuno K, Hoshino Y, Nagamune K, Kubo S, Yagi M, Yamaguchi M, Yoshiya S, Kurosaka M (2009) Analysis of the graft bending angle at the femoral tunnel aperture in anatomic double bundle anterior cruciate ligament reconstruction: a comparison of the transtibial and the far anteromedial portal technique. Knee Surg Sports Traumatol Arthrosc 17(3):270–276

    Article  PubMed  Google Scholar 

  31. Peyrache MD, Djian P, Christel P, Witvoet J (1996) Tibial tunnel enlargement after anterior cruciate ligament reconstruction by autogenous bone-patellar tendon-bone graft. Knee Surg Sports Traumatol Arthrosc 4(1):2–8

    Article  CAS  PubMed  Google Scholar 

  32. Rodeo SA, Kawamura S, Kim HJ, Dynybil C, Ying L (2006) 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 34(11):1790–1800

    Article  PubMed  Google Scholar 

  33. Segawa H, Koga Y, Omori G, Sakamoto M, Hara T (2003) Influence of the femoral tunnel location and angle on the contact pressure in the femoral tunnel in anterior cruciate ligament reconstruction. Am J Sports Med 31(3):444–448

    Article  PubMed  Google Scholar 

  34. Sidles JA, Larson RV, Garbini JL, Downey DJ, Matsen FA 3rd (1988) Ligament length relationships in the moving knee. J Orthop Res 6(4):593–610

    Article  CAS  PubMed  Google Scholar 

  35. Silva A, Sampaio R, Pinto E (2010) Femoral tunnel enlargement after anatomic ACL reconstruction: a biological problem? Knee Surg Sports Traumatol Arthrosc 18(9):1189–1194

    Article  PubMed  Google Scholar 

  36. Simonian PT, Erickson MS, Larson RV, O’Kane JW (2000) Tunnel expansion after hamstring anterior cruciate ligament reconstruction with 1-incision EndoButton femoral fixation. Arthroscopy 16:707–714

    Article  CAS  PubMed  Google Scholar 

  37. Snyder-Mackler L, Fitzgerald GK, Bartolozzi AR 3rd, Ciccotti MG (1997) The relationship between passive joint laxity and functional outcome after anterior cruciate ligament injury. Am J Sports Med 25(2):191–195

    Article  CAS  PubMed  Google Scholar 

  38. Tachibana Y, Mae T, Shino K, Kanamoto T, Sugamoto K, Yoshikawa H, Nakata K (2015) Morphological changes in femoral tunnels after anatomic anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 23(12):3591–3600

    Article  PubMed  Google Scholar 

  39. Tsuda E, Fukuda Y, Loh JC, Debski RE, Fu FH, Woo SL (2002) The effect of soft-tissue graft fixation in anterior cruciate ligament reconstruction on graft-tunnel motion under anterior tibial loading. Arthroscopy 18(9):960–967

    Article  PubMed  Google Scholar 

  40. van Eck CF, Gravare-Silbernagel K, Samuelsson K, Musahl V, van Dijk CN, Karlsson J, Irrgang JJ, Fu FH (2013) Evidence to support the interpretation and use of the Anatomic Anterior Cruciate Ligament Reconstruction Checklist. J Bone Joint Surg Am 95(20):e153

    Article  PubMed  Google Scholar 

  41. Weber AE, Delos D, Oltean HN, Vadasdi K, Cavanaugh J, Potter HG, Rodeo SA (2015) Tibial and femoral tunnel changes after ACL reconstruction: a prospective 2-year longitudinal MRI study. Am J Sports Med 43(5):1147–1156

    Article  PubMed  Google Scholar 

  42. Wilson TC, Kantaras A, Atay A, Johnson DL (2004) Tunnel enlargement after anterior cruciate ligament surgery. Am J Sports Med 32(2):543–549

    Article  PubMed  Google Scholar 

  43. Yasuda K, van Eck CF, Hoshino Y, Fu FH, Tashman S (2011) Anatomic single- and double-bundle anterior cruciate ligament reconstruction, part 1: basic science. Am J Sports Med 39(8):1789–1799

    Article  PubMed  Google Scholar 

  44. Zavras TD, Race A, Bull AM, Amis AA (2001) A comparative study of ‘isometric’ points for anterior cruciate ligament graft attachment. Knee Surg Sports Traumatol Arthrosc 9(1):28–33

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Kobe Kaisei Hospital, 11-15, Shinohara-Kitamachi, 3-chome, Nada-ku, Kobe, 657-0068, Japan

    Yuichi Hoshino & Shinya Oka

  2. Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan

    Ryosuke Kuroda, Yuichiro Nishizawa, Naoki Nakano, Kanto Nagai, Daisuke Araki & Masahiro Kurosaka

  3. Department of Human and Artificial Intelligent Systems, Graduate School of Engineering, University of Fukui, Fukui, Japan

    Shogo Kawaguchi & Kouki Nagamune

Authors
  1. Yuichi Hoshino
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  2. Ryosuke Kuroda
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  4. Naoki Nakano
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  5. Kanto Nagai
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  10. Masahiro Kurosaka
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Correspondence to Yuichi Hoshino.

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The authors have no conflicts of interests in the current study.

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This work was performed at Kobe University where research involving de-identified cadaveric specimens was exempted from IRB review at the time of the experiment.

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Hoshino, Y., Kuroda, R., Nishizawa, Y. et al. Stress distribution is deviated around the aperture of the femoral tunnel in the anatomic anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 26, 1145–1151 (2018). https://doi.org/10.1007/s00167-017-4543-5

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