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Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 26, Issue 8, pp 2430–2437 | Cite as

ACL graft compression: a method to allow reduced tunnel sizes in ACL reconstruction

  • Breck R. Lord
  • Henry B. Colaco
  • Chinmay M. Gupte
  • Adrian J. Wilson
  • Andrew A. Amis
Knee

Abstract

Purpose

A common problem during ACL reconstruction is asymmetry of proximal–distal graft diameter leading to tunnel upsizing and graft–tunnel mismatch. Compression downsizing provides a graft of uniform size, allowing easy passage into a smaller tunnel. The purpose of this study was to quantify the graft compression technique and its effects on graft biomechanics and stability. It was hypothesised that compression downsizing would significantly reduce cross-sectional area (CSA); that no significant changes in graft biomechanics would occur; graft fixation stability would be improved.

Method

Sixty-eight non-irradiated peroneus longus (PL) tendons were investigated. Twenty were halved and paired into ten four-strand grafts, 20 strands were compressed by 0.5–1 mm diameter and changes in CSA recorded using an alginate mould technique. The following properties were compared with 20 control strands: cyclic strain when loaded 70–220 N for 1000 cycles; stiffness; ultimate tensile load and stress; Young’s modulus. 24 PL tendons were quadrupled into grafts, 12 were compressed and all 24 were submerged in Ringer’s solution at 37 °C and the CSA recorded over 12 h. Twelve compressed and 12 control quadrupled grafts were mounted in porcine femurs, placed in Ringer’s solution for 12 h at 37 °C and graft displacement at the bone tunnel aperture recorded under cyclic loading.

Results

Mean decreases in CSA of 31% under a stress of 471 kPa and 21% under a stress of 447 kPa were observed for doubled and quadrupled grafts, respectively. Compressed grafts re-expanded by 19% over 12 h compared to 2% for controls. No significant differences were observed between compressed and control grafts in the biomechanical properties and graft stability; mean cyclic displacements were 0.3 mm for both groups.

Conclusions

No detrimental biomechanical effects of graft compression on allograft PL tendons were observed. Following compression, the grafts significantly increased in size during in vitro joint simulation. No significant difference was observed in graft stability between groups. Graft compression did not cause adverse mechanical effects in vitro. Smaller tunnels for compressed grafts reduce bone loss and ease anatomical placement.

Keywords

Anterior cruciate ligament ACL reconstruction Compression downsizing Tendon graft biomechanics 

Abbreviations

ACL

Anterior cruciate ligament

ACLR

Anterior cruciate ligament reconstruction

ANOVA

Analysis of variance

CSA

Cross-sectional area

ICC

Intraclass correlation coefficients

n.s.

Non-significant

PL

Peroneus longus

SD

Standard deviation

SPSS

Statistical Package for the Social Sciences

USA

United States of America

UFL

Ultimate failure load

UTS

Ultimate tensile stress

Notes

Funding

BRL was supported by the Orthopaedic Research Fund of the North Hampshire Hospital. The Instron materials testing machine was donated by the Arthritis Research UK charity. The tendon specimens were donated by RTI Surgical Co., Florida, USA.

Compliance with ethical standards

Conflict of interest

None declared.

Ethical approval

This study was approved by the Imperial College Healthcare Tissue Bank, HTA licence 12275, REC Wales approval 12/WA/0196, project R13058.

Informed consent

Not required for this study, which was covered by a Research Ethics Committee permit.

References

  1. 1.
    Wolf RS, Lemak LJ (2002) Revision anterior cruciate ligament reconstruction surgery. J South Orthop Assoc 11:25–32PubMedGoogle Scholar
  2. 2.
    Siebold R, Cafaltzis K (2010) Differentiation between intraoperative and postoperative bone tunnel widening and communication in double-bundle anterior cruciate ligament reconstruction: a prospective study. Arthroscopy 26:1066–1073CrossRefPubMedGoogle Scholar
  3. 3.
    Silva A, Sampaio R, Pinto E (2010) Femoral tunnel enlargement after anatomic ACL reconstruction: a biological problem? Knee Surg, Sports Traumatol Arthrosc 18:1189–1194CrossRefGoogle Scholar
  4. 4.
    Baumfeld JA, Diduch DR, Rubino LJ, Hart JA, Miller MD, Barr MS et al (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 16:1108–1113CrossRefPubMedGoogle Scholar
  5. 5.
    Clatworthy MG, Annear P, Bulow JU, Bartlett RJ (1999) Tunnel widening in anterior cruciate ligament reconstruction: a prospective evaluation of hamstring and patella tendon grafts. Knee Surg Sports Traumatol Arthrosc 7:138–145CrossRefPubMedGoogle Scholar
  6. 6.
    Hoher J, Moller HD, Fu FH (1998) Bone tunnel enlargement after anterior cruciate ligament reconstruction: fact or fiction? Knee Surg Sports Traumatol Arthrosc 6:231–240CrossRefPubMedGoogle Scholar
  7. 7.
    Lee YS, Lee S-W, Nam SW, Oh WS, Sim JA, Kwak JH et al (2012) Analysis of tunnel widening after double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 20:2243–2250CrossRefPubMedGoogle Scholar
  8. 8.
    Paessler HH, Mastrokalos DS (2003) Anterior cruciate ligament reconstruction using semitendinosus and gracilis tendons, bone patellar tendon, or quadriceps tendon–graft with press-fit fixation without hardware: A new and innovative procedure. Orthop Clin N Am 34:49–64CrossRefGoogle Scholar
  9. 9.
    Lind M, Menhert F, Pedersen AB (2009) The first results from the Danish ACL reconstruction registry: epidemiologic and 2 year follow-up results from 5,818 knee ligament reconstructions. Knee Surg Sports Traumatol Arthrosc 17:117–124CrossRefPubMedGoogle Scholar
  10. 10.
    Morgan MD, Salmon LJ, Waller A, Roe JP, Pinczewski LA (2016) Fifteen-year survival of endoscopic anterior cruciate ligament reconstruction in patients aged 18 years and younger. Am J Sports Med 44:384–392CrossRefPubMedGoogle Scholar
  11. 11.
    Cunningham R, West JR, Greis PE, Burks RT (2002) A survey of the tension applied to a doubled hamstring tendon graft for reconstruction of the anterior cruciate ligament. Arthroscopy 18:983–988CrossRefPubMedGoogle Scholar
  12. 12.
    Palmer JE, Russell JP, Grieshober J, Iacangelo A, Ellison BA, Lease TD, Kim H, Henn RF, Hsieh AH (2017) A biomechanical comparison of allograft tendons for ligament reconstruction. Am J Sports Med 45:701–707CrossRefPubMedGoogle Scholar
  13. 13.
    Goodship AE, Birch HL (2005) Cross sectional area measurement of tendon and ligament in vitro: a simple, rapid, non-destructive technique. J Biomech 38:605–608CrossRefPubMedGoogle Scholar
  14. 14.
    Lubowitz JH, Ahmad CS, Anderson K (2011) All-inside anterior cruciate ligament graft-link technique: second-generation, no-incision anterior cruciate ligament reconstruction. Arthroscopy 27:717–727CrossRefPubMedGoogle Scholar
  15. 15.
    Anderson CJ, Westerhaus BD, Pietrini SD, Ziegler CG, Wijdicks CA, Johansen S et al (2010) Kinematic impact of anteromedial and posterolateral bundle graft fixation angles on double-bundle anterior cruciate ligament reconstructions. Am J Sports Med 38:1575–1583CrossRefPubMedGoogle Scholar
  16. 16.
    Amis AA, Dawkins GP (1991) Functional anatomy of the anterior cruciate ligament. Fibre bundle actions related to ligament replacements and injuries. J Bone Joint Surg Br 73:260–267CrossRefPubMedGoogle Scholar
  17. 17.
    Riemersa DJ, Schamhardt HC (1982) The cryo-jaw, a clamp designed for in vitro rheology studies of horse digital flexor tendons. J Biomech 15:619–620CrossRefPubMedGoogle Scholar
  18. 18.
    Andersen HN, Amis AA (1994) Review on tension in the natural and reconstructed anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 2:192–202CrossRefPubMedGoogle Scholar
  19. 19.
    Ahn JH, Lee SH, Yoo JC, Ha HC (2007) Measurement of the graft angles for the anterior cruciate ligament reconstruction with transtibial technique using postoperative magnetic resonance imaging in comparative study. Knee Surg Sports Traumatol Arthrosc 15:1293–1300CrossRefPubMedGoogle Scholar
  20. 20.
    Kondo E, Merican AM, Yasuda K, Amis AA (2011) Biomechanical comparison of anatomic double-bundle, anatomic single-bundle, and nonanatomic single-bundle anterior cruciate ligament reconstructions. Am J Sports Med 39:279–288CrossRefPubMedGoogle Scholar
  21. 21.
    Desai N, Björnsson H, Musahl V, Bhandari M, Petzold M, Fu FH et al. (2014) Anatomic single-versus double-bundle ACL reconstruction: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 22:1009–1023CrossRefPubMedGoogle Scholar
  22. 22.
    Hussein M, van Eck CF, Cretnik A, Dinevski D, Fu FH (2012) Prospective randomized clinical evaluation of conventional single-bundle, anatomic single-bundle, and anatomic double-bundle anterior cruciate ligament reconstruction: 281 cases with 3- to 5-year follow-up. Am J Sports Med 40:512–520CrossRefPubMedGoogle Scholar
  23. 23.
    Adams AL, Schiff MA (2006) Childhood soccer injuries treated in US emergency departments. Acad Emerg Med 13:571–574CrossRefPubMedGoogle Scholar
  24. 24.
    Majewski M, Susanne H, Klaus S (2006) Epidemiology of athletic knee injuries: A 10-year study. Knee 13:184–188CrossRefPubMedGoogle Scholar
  25. 25.
    Maffulli N, Del Buono A (2013) Anterior cruciate ligament tears in children. Surgeon 11:59–62CrossRefPubMedGoogle Scholar
  26. 26.
    Śmigielski R, Zdanowicz U, Drwięga M, Ciszek B, Ciszkowska-Łysoń B, Siebold R (2014) Ribbon like appearance of the midsubstance fibres of the anterior cruciate ligament close to its femoral insertion site: a cadaveric study including 111 knees. Knee Surg Sports Traumatol Arthrosc 22:1–8Google Scholar
  27. 27.
    Lehmann A-K, Osada N, Zantop T, Raschke MJ, Petersen W (2009) Femoral bridge stability in double-bundle ACL reconstruction: impact of bridge width and different fixation techniques on the structural properties of the graft/femur complex. Arch Orthop Trauma Surg 129:1127–1132CrossRefPubMedGoogle Scholar
  28. 28.
    Hwang DH, Shetty GM, Kim JI, Kwon JH, Song JK, Munoz M et al (2013) Does press-fit technique reduce tunnel volume enlargement after anterior cruciate ligament reconstruction with autologous hamstring tendons? A prospective randomized computed tomography study. Arthroscopy 29:83–88CrossRefPubMedGoogle Scholar
  29. 29.
    Woo SL, Hollis JM, Adams DJ, Lyon RM, Takai S (1991) Tensile properties of the human femur-anterior cruciate ligament-tibia complex. The effects of specimen age and orientation. Am J Sports Med 19:217–225CrossRefPubMedGoogle Scholar
  30. 30.
    Noyes F, Butler D, Grood E, Zernicke R, Hefzy M (1984) Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions. J Bone Joint Surg Am 66:344–352CrossRefPubMedGoogle Scholar
  31. 31.
    Wilson TW, Zafuta MP, Zobitz M (1999) A biomechanical analysis of matched bone-patellar tendon-bone and double-looped semitendinosus and gracilis tendon grafts. Am J Sports Med 27:202–207CrossRefPubMedGoogle Scholar
  32. 32.
    Pearsall AW, Hollis JM, Russell GV, Scheer Z (2003) A biomechanical comparison of three lower extremity tendons for ligamentous reconstruction about the knee. Arthroscopy 19:1091–1096CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Authors and Affiliations

  1. 1.The Biomechanics Group, Department of Mechanical EngineeringImperial College LondonLondonUK
  2. 2.Basingstoke and North Hampshire HospitalBasingstokeUK
  3. 3.St Georges HospitalLondonUK
  4. 4.Musculoskeletal Surgery Group, Department of Surgery and CancerImperial College London School of Medicine, Charing Cross HospitalLondonUK

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