A new remnant preservation technique reduces bone tunnel enlargement after anatomic double-bundle anterior cruciate ligament reconstruction

Abstract

PurposeTo investigate the effect of a new remnant preservation technique with a focus on remnant continuity on postoperative femoral and tibial tunnel enlargement after anatomical double‐bundle anterior cruciate ligament reconstruction (ACLR). MethodsA total of 150 knees were divided into three groups: Preservation Group (Group P: 49 knees), wherein the remnant continuity remained after tunnel creation; Resection Group (Group R: 47 knees), wherein the remaining remnant was resected, and Absent Group (Group A: 54 knees), wherein the remnant had no femoral attachment before tunnel creation. In Group P, the remnant maintained continuity, and the anteromedial (AM) and posterolateral (PL) bundles were positioned anterior and posterior to the remnant, respectively. Computed tomographic scans were performed at 1 week and 1 year after surgery, and the cross‐sectional area of each tunnel aperture was measured. Tunnel enlargement was compared among the three groups by one‐way analysis of variance (ANOVA) and the Bonferroni test. Univariate and multivariate logistic analyses were performed to identify the risk factors for tunnel enlargement in demographic and radiographic data. ResultFor femoral AM tunnels, the tunnel enlargement of Group P was significantly smaller than Groups R and A (p < 0.001), femoral PL (p < 0.001 vs. R and A), tibial AM (p < 0.001 vs. R, 0.002 vs. A), and tibial PL (p < 0.001 vs. R, 0.002 vs. A). There was no significant difference between Groups R and A. Multivariate logistic analysis showed that remnant preservation was a significant factor in reducing tunnel enlargement in the femoral AM, femoral PL, tibial AM, and tibial PL. ConclusionThe new remnant‐preserving anatomical double‐bundle ACLR, which preserves the continuity of the remnant, prevented all bone tunnel enlargement at 1 year postoperatively. Level of evidenceLevel III.

Effect of a new remnant-preserving technique with anatomical double-bundle anterior cruciate ligament reconstruction on MRI-based graft maturity: a comparison cohort study

“…This new remnant‐preserving ACLR technique has been reported to improve stability as compared to the remnant resection or absent technique, although it did not affect clinical outcomes including the Lysholm knee score, Tegner activity scale, and the International Knee Documentation Committee (IKDC) subjective scores [13] and reduce bone tunnel enlargement [17], in addition to the results of the present study. Franciozi et al [9] also compared a functional preservation group in single‐bundle ACLR, in which continuity with the femur was maintained through the placement of the graft outside the remnant, with a nonfunctional preservation group, in which continuity was broken through the graft placed inside the remnant.…”

“…Through this technique, reduction of the initial stress on the graft and achievement of better remodeling are expected. While this technique has been reported to improve postoperative knee stability [13] and reduce bone tunnel enlargement [17], there are no reports on the effects of this procedure on graft maturity to date. If this new technique exhibits a positive impact on graft maturity, it may enable early return to sports and reduce the risk of re‐rupture due to poor maturation of the reconstructed ligament.…”

Graft impingement increases anterior cruciate ligament graft signal more than acute graft bending angle: magnetic resonance imaging‐based study in outside‐in anterior cruciate ligament reconstruction

“…In the present study, we included patients who underwent an outside‐in procedure using a transseptal portal, which is a precise method for achieving anatomic ACLR and preserving the remnant bundle. The ACL remnant could have a cushioning effect, reducing the repetitive bending stress on the graft due to the acute angle of the femoral tunnel‐graft and decreasing the signal of the proximal third of the graft, near the femoral aperture [15, 17].…”

The apex of the deep cartilage is a stable landmark to position the femoral tunnel during remnant‐preserving anterior cruciate ligament reconstruction

“…Third, because of the remnant, the space between the residual tissue and the proximal articular surface decreased, which might lead to a more difficult surgical procedure. Thus, some surgeons choose to sacrifice a part of the remnant for a better view to locate the femoral tunnel more accurately [21, 35], but the function of remnants might be depleted. Therefore, it is still necessary to find a method to position the femoral tunnel that is appropriate for remnant preservation.…”

“…Although remnant preservation (RP) does not have a significant advantage in terms of clinical outcomes, it may offer several benefits. According to multiple clinical studies, in comparison to nonremnant preservation (NRP), RP may offer better graft vascularization, greater preservation of proprioception and less tibial tunnel enlargement [5, 21, 42]. All of these advantages may result in better outcomes of knee mechanical stability [12, 15, 21, 32].…”