Knee Surgery, Sports Traumatology, Arthroscopy

https://doi.org/10.1007/s00167-019-05642-9

KNEE

ACL reconstruction with adjustable‑length loop cortical

button fixation results in less tibial tunnel widening compared
with interference screw fixation
Raul Mayr1 · Vinzenz Smekal2 · Christian Koidl1 · Christian Coppola1 · Martin Eichinger1 · Ansgar Rudisch3 ·
Christof Kranewitter3 · René Attal4

Received: 28 January 2019 / Revised: 15 July 2019 / Accepted: 19 July 2019

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Abstract
Purpose  To compare tunnel widening and clinical outcome after anterior cruciate ligament reconstruction (ACLR) with
interference screw fixation and all-inside reconstruction using button fixation.
Methods  Tunnel widening was assessed using tunnel volume and diameter measurements on computed tomography (CT)
scans after surgery and 6 months and 2 years later, and compared between the two groups. The clinical outcome was assessed
after 2 years with instrumented tibial anteroposterior translation measurements, hop testing and International Knee Docu-
mentation Committee (IKDC), Lysholm and Tegner activity scores.
Results  The study population at the final follow-up was 14 patients with screw fixation and 16 patients with button fixation.
Tibial tunnels with screw fixation showed significantly larger increase in tunnel volume over time (P = 0.021) and larger tun-
nel diameters after 2 years in comparison with button fixation (P < 0.001). There were no significant differences in femoral
tunnel volume changes over time or in tunnel diameters after 2 years. No significant differences were found in the clinical
outcome scores.
Conclusions  All-inside ACLR using button fixation was associated with less tibial tunnel widening and smaller tunnels after
2 years in comparison with ACLR using screw fixation. The need for staged revision ACLRs may be greater with interference
screws in comparison with button fixation at the tibial tunnel. The clinical outcomes in the two groups were comparable.
Level of evidence II.
RCT: Consort NCT01755819.

Keywords  Anterior cruciate ligament · ACL · Tunnel enlargement · Tunnel widening · Fixation · All-inside · Button ·
Screw

Introduction

Postoperative tunnel widening is a phenomenon that has

been widely reported with the use of soft-tissue grafts
Investigation performed at the Department of Trauma Surgery, for anterior cruciate ligament (ACL) reconstruction [9,
Medical University Innsbruck, Austria. 12, 15, 18, 40]. Mechanical and biological factors have
been postulated as causes of tunnel widening, but the
Electronic supplementary material  The online version of this
article (https​://doi.org/10.1007/s0016​7-019-05642​-9) contains phenomenon may be multifactorial. Micromovements
supplementary material, which is available to authorized users.

3
* René Attal Department of Radiology, Medical University Innsbruck,
rene.elattal@lkhf.at Innsbruck, Austria
4
1 Department of Trauma Surgery and Sports Traumatology,
Department of Trauma Surgery, Medical University
Academic Hospital Feldkirch, LKH Feldkirch, Carinagasse
Innsbruck, Innsbruck, Austria
47, 6807 Feldkirch, Austria
2
AUVA Trauma Center Klagenfurt, Klagenfurt, Austria

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 Knee Surgery, Sports Traumatology, Arthroscopy

at the tendon–bone interface have been shown to cause fixation. The second hypothesis was that the two techniques
tunnel widening in experimental animal studies [36, would result in comparable clinical outcomes.
39]. Mechanical factors reported to affect tunnel widen-
ing include aggressive rehabilitation and increased graft
forces due to improper graft placement [15, 42]. Biologi- Materials and methods
cal factors include the surface area for tendon–bone heal-
ing, influx of synovial fluid into the tunnel, nonspecific Forty-seven patients were enrolled from 2013 to 2016 in a
inflammatory responses, cell necrosis in the graft during prospective randomized study. The patients were randomly
remodelling, immune response to allografts, toxic effects assigned either to the ACL reconstruction technique using
of ethylene oxide gas, cell necrosis due to drilling and interference screw fixation on the femoral and tibial graft
foreign-body reactions [15, 17, 19, 34, 35]. Although or to all-inside ACL reconstruction using adjustable-length
most studies have not reported any negative associations loop cortical button fixation. Block randomization was used
between tunnel widening and the clinical outcome [12, to assign eligible patients to the treatment arms. Patients
18, 40, 43], large tunnels may compromise graft fixation aged 18–45 years were included if they met the following
during revision surgery or may require two-stage surgery. inclusion criteria: (1) unilateral ACL rupture diagnosed clin-
With interference screw fixation, the graft is compressed ically and on magnetic resonance imaging (MRI); (2) a time
against the tunnel wall, allowing for fixation close to the interval between ACL injury and reconstruction of 1 year;
joint. This may reduce graft–tunnel movement and reduce (3) Tegner activity score ≥ 5; (4) a normal contralateral knee.
the influx of synovial fluid into the tunnel. Concerns that Major exclusion criteria were total collateral ligament rup-
have been raised in relation to interference screw fixation ture, a full-thickness cartilage lesion and an unstable lon-
include graft and tunnel damage during screw insertion, gitudinal meniscus tear (requiring meniscus refixation and
foreign-body reactions and poor integration of the screw changes in the postoperative rehabilitation protocol) visual-
[33]. Biodegradable interference screws composed of ized on MRI or arthroscopically (Appendix, Table 1).
biphasic calcium phosphate and poly(l-lactide-co-d,l-lac- Twenty-three patients were allocated to the group with
tide) PLDLA are designed to allow osseous integration and screw fixation and 24 patients to the all-inside reconstruc-
reduce postoperative tunnel widening. tion group with button fixation. The flow diagram for the
With all-inside ACL reconstruction techniques, graft fixa- patients is shown in Fig. 1. Intraoperatively, patients were
tion can be achieved using adjustable-length loop cortical excluded because of unstable meniscus tears in four patients
button devices on the femoral and tibial sides. The graft is with screw fixation and in one patient with button fixation.
prepared in a tendon loop with securing sutures [23]. The Complications during surgery related to the fixation tech-
graft has full contact within the bone socket without any nique included one femoral screw breakage, one button mis-
foreign material, which may allow early graft integration location in the femoral tunnel and one loop rupture of the
[37]. Concerns regarding the all-inside graft preparation femoral button. Three patients with button fixation sustained
and fixation technique were raised in laboratory studies that early repeat rupture within 6 months (one soccer, two low-
showed high graft and button loop elongation, potentially energy knee distortions). One patient with button fixation
resulting in graft micromotion at the bone–tendon interface presented with septic arthritis 2 weeks after surgery and was
[2, 13, 27, 28, 36, 38]. Graft elongation is associated with treated with two irrigations and graft retention. This patient
increased knee laxity and poorer subjective knee function [7, showed ACL insufficiency at the follow-up examination after
20]. Clinical studies reported good functional outcomes and 1 year and was excluded from the final analysis. One patient
less pain on the tibial side in comparison with conventional with screw fixation underwent a partial medial meniscus
full tibial tunnel drilling [3, 24, 25, 32]. resection 12 months after ACL reconstruction and medial
To date, there have been no prospective randomized trials meniscal repair. One patient in the button group underwent
reporting on clinical outcomes and tunnel volume changes repeat surgery 18 months after ACL reconstruction for a
after the all-inside ACL reconstruction technique using two cyclops lesion and tibial button removal.
adjustable-length loop cortical buttons in comparison with Knee CT scans were performed within 3 days after sur-
ACL reconstruction with interference screw fixation. The gery and after 6 months and 2 years postoperatively.
aim of the present study was therefore to compare postopera-
tive tunnel widening and clinical outcomes after ACL recon- Surgical technique
struction with interference screw fixation or all-inside ACL
reconstruction using button fixation. The first hypothesis was Screw fixation
that ACL reconstruction with interference screw fixation
results in less postoperative tunnel widening in compari- The semitendinosus and gracilis tendon were harvested.
son with all-inside reconstruction using extracortical button The tendon ends were whipstitched using a non-resorbable

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Knee Surgery, Sports Traumatology, Arthroscopy

Fig. 1  Patient flow diagram 83 sceened for eligibility from 01/2013 - 02/2016

Patients enrolled (n=47)

Screw (n=23) All-inside (n=24)

Intraoperave exclusion Intraoperave exclusion

4 Meniscus refixation 1 Meniscus refixation

83 complications
1 intraoperative 2 intraoperative complications
(screw breakage) (button mislocation, button loop rupture)

Postoperave complicaons

1 septic arthritis

3 early reruptures

4 lost on follow up 1 lost on follow up

N=14 N=16 2 years Follow up

suture (FiberWire #2; Arthrex Inc., Naples, Florida, USA). than the tunnel diameter. A full tibial tunnel was created
A four-stranded tendon graft and graft strands were pre- in the tibial ACL stump using a drill guide. The tibial ACL
pared. The mean graft size was 7.3 ± 0.5 mm on the femo- stump was preserved. The knee was cycled approximately
ral side and 7.9 ± 0.8 mm on the tibial side. The femoral 10 times for graft preconditioning. The graft was fixed at
tunnel was drilled through the anteromedial portal at the 30° of flexion by inserting the bioabsorbable interference
centre of the femoral ACL insertion site and the graft was screw (BioComposite; Arthrex Inc.) into the tibial tunnel
fixed using a 23-mm long bioabsorbable interference screw aperture using the length scale on the screwdriver. The
(BioComposite; Arthrex Inc.) with a diameter 1 mm less screw diameter selected was 1 mm larger than the tunnel
diameter and the screw length was 28 mm (Fig. 2a).

Fig. 2  Anterior cruciate
ligament (ACL) reconstruc-
tion using interference screw
fixation with whipstitched
tendon ends (green dots) (a) or
all-inside ACL reconstruction
using button fixation with secur-
ing sutures (red lines) (b)

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 Knee Surgery, Sports Traumatology, Arthroscopy

Button (512 × 512 voxels). Images were acquired at 100 kV and

120–400 mAs, with a noise index of 25.
The semitendinosus tendon was harvested. The tendon was The bone tunnel volume was measured on the axial slices.
folded over the loop of an adjustable-length loop cortical In the group with interference screw fixation, the screw vol-
button (TightRope RT; Arthrex Inc.) and the two tendon ume was included in the measurement. The cross-sectional
ends were whipstitched together using a non-resorbable area of the bone tunnel was added up and multiplied to cal-
suture (FiberWire #2; Arthrex Inc.). The two tendon ends culate the total volume on every third slice (AW Server 2.0;
were passed through another cortical button loop in order GE Healthcare). The interrater intraclass correlation coef-
to obtain a four-stranded graft. The two graft ends were ficient (ICC) with this measurement technique has been
secured with two sutures (FiberWire #2; Arthrex Inc.) in reported to be between 0.606 and 0.922 [30].
a buried-knot technique as described by Lubowitz [23]. CT images were used for tunnel diameter measurements.
The mean length of the tendon graft was 67.2 ± 3.6 mm. The images were orientated along the longitudinal axis of
The mean graft size was 7.7 ± 0.8 mm on the femoral side the femoral and tibial tunnel. The maximum diameter of the
and 8.0 ± 0.5 mm on the tibial side. The femoral tunnel was tunnel was measured. ACL tunnel placement was measured
drilled at the centre of the femoral ACL insertion area. Fem- on the sagittal slices of the postoperative CT scan. The femo-
oral tunnel drilling was performed using the anteromedial ral tunnel location was evaluated using the quadrant method
(AM) portal reaming technique in five patients, and with an on the lateral femoral condyle, as described by Bernard et al.
outside-in technique using a retrograde drilling guide pin in [4]. The centre of the femoral tunnel was measured in the
11 patients (FlipCutter; Arthrex Inc.). The tibial socket was proximal–distal direction, normalized to the Blumensaat line
created at the tibial ACL stump using a retrograde drilling and the dorsal–anterior location was measured as the dis-
guide pin (FlipCutter; Arthrex Inc.), preserving the tibial tance from the most posterior contour of the lateral femoral
ACL stump as much as possible. A minimum of 7 mm corti- condyle. The interrater ICC has been reported to be between
cal bone bridge was left. After graft insertion, the knee was 0.729 and 0.895 [31]. The location of the tibial tunnel was
cycled approximately 10 times for graft preconditioning. The evaluated along the Amis and Jakob line (the distance from
graft was finally tensioned by shortening the loop of the the anterior margin on the tibia to the centre of the tibial
adjustable-length loop cortical buttons on the femoral and tunnel, expressed as a percentage of the anteroposterior tib-
tibial sides at 30° of flexion (Fig. 2b). ial length) [1]. An ICC of 0.934 has been reported for this
measurement method [16].
Rehabilitation The study protocol was approved by the ethics commit-
tee at the Medical University of Innsbruck (ID: UN4820
Active quadriceps exercise and passive knee motion were 316/4.22). The study was planned and conducted in accord-
performed starting from the first day. Full weight-bearing ance with the Consolidated Standards on Reporting Trials
was immediately allowed. A knee brace was worn for (CONSORT) guidelines (NCT01755819). All of the patients
2 weeks postoperatively. From weeks 4 to 12, cycling, mus- provided written informed consent prior to surgery.
cle training and swimming were permitted. Running was
allowed after 12 weeks. Full exercise activity was allowed Statistical analysis
after 6–9 months.
Statistical analysis was performed using IBM SPSS Statis-
Clinical outcome tics for Windows, version 25.0 (IBM Corporation, Armonk,
New York, USA). Parametric data are presented as mean
The clinical outcome was assessed at the 2-year follow-up with standard deviation (SD). The Kolmogorov–Smirnov
appointment, with assessment of the IKDC, Lysholm and test was used to check whether the data were normally dis-
Tegner activity scores, hop testing and KT-1000 measure- tributed. Groups were compared using Student’s t test for
ment. Anteroposterior knee stability after 2 years, assessed normally distributed data and the Mann–Whitney U test
using the KT-1000 knee instrumented laxity measuring for non-normally distributed data. Categorical data were
device (MEDmetric, San Diego, California, USA), was analysed using Fisher’s exact test and expressed as absolute
defined as the primary clinical outcome parameter. numbers and percentage distributions.
Changes in the absolute tunnel volume over time were
Radiological measurements compared between the two study groups using two-way
analysis of variance (ANOVA) with repeated measurements.
Multidetector CT scanning (GE Discovery CT 750 HD; To account for possible sphericity violation among states,
GE Healthcare, Chicago, Illinois, USA) was performed the P values were corrected in accordance with the Green-
on the operated knee. The slice thickness was 0.625 mm house–Geisser method [14].

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Knee Surgery, Sports Traumatology, Arthroscopy

Reported P values are two-sided, with significance set Early repeat rupture within 6 months was observed in three
at < 0.05. patients with button fixation.
An effect size of 1.0 units was deemed relevant when
comparing changes in tunnel widening (difference in means:
10%, SD 10%), KT-1000 (2 mm, SD 2 mm) and Lysholm Tunnel widening
score (2 points, SD 2) between the two groups. To achieve
this with a power of 80% using a two-group t test with a The tibial tunnel volume with button fixation was sig-
two-sided significance level of P < 0.05, a sample size of nificantly smaller at all three measurement time points
17 in each treatment group is required. Data for the final (P < 0.001) (Table 2). The increase in the tibial tunnel vol-
follow-up were available for 14 patients with screw fixation ume over time was significantly larger in the group with
and 16 patients with button fixation, and a power of 80% was screw fixation (Fig. 3a) (P = 0.021).
therefore not reached. The femoral tunnel volume with button fixation was
significantly smaller at baseline in comparison with screw
fixation (P = 0.025). After 6 months and 2 years, the differ-
Results ences between the groups were not significant (Table 2). The
change in femoral tunnel volume over time did not differ
There were no significant differences in the patients’ demo- significantly between the two groups (Fig. 3b).
graphic characteristics in relation to age, sex, body mass The maximum tibial tunnel diameter was significantly
index (BMI), or preinjury Tegner score. The mean operating larger with screw fixation at all three time points (P < 0.001).
time was significantly longer in the button group (Table 1). The femoral tunnel was larger with screw fixation at time

Table 1  Descriptive data of the Screw fixation (n = 14) Button fixation (n = 16) P value
study population
Age (y) 29 ± 7 25 ± 6 n.s
Sex (m, f)
 Female 4 (29%) 5 (31%)
 Male 10 (71%) 11 (69%) n.s
BMI 24.2 ± 2.0 24.1 ± 4.5 n.s
Tegner 7 (6–9) 7 (5–9) n.s
Surgical time 72.5 ± 22.7 93.1 ± 23.7 0.022
Partial meniscectomy (medial/lateral) 4 (3/1) 3 (3/0) n.s
Meniscus refixation (medial/lateral) 1 (1/0) 1 (1/0) n.s

Data are shown as mean ± standard deviation, median (range), n (%). BMI, body mass index

Table 2  Tunnel volume and location

 Group (cm3) Location (%)
Postoperative 6 months 24 months AJ

Tibial tunnel
 Screw 2.6 ± 0.5 2.9 ± 0.7 2.9 ± 0.7 41.2 ± 7.1
 Button 1.1 ± 0.3 1.3 ± 0.5 1.1 ± 0.4 40.7 ± 4.1
 P value < 0.001 < 0.001 < 0.001 n.s
 Group Postoperative 6 months 24 months PD PA

Femoral tunnel
 Screw 1.2 ± 0.2 1.4 ± 0.4 1.4 ± 0.5 38.4 ± 9.6 24.8 ± 5.7
 Button 1.0 ± 0.3 1.3 ± 0.4 1.1 ± 0.4 33.6 ± 12.4 31.9 ± 6.7
 P value 0.025 n.s n.s n.s 0.004

Data are shown as mean with standard deviation

AJ tibial tunnel location along Amis and Jakob line, PD proximal–distal distance from Blumensaat line in percent, PA posterior-anterior distance
from posterior contour of lateral femoral condyle in percent

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 Knee Surgery, Sports Traumatology, Arthroscopy

Fig. 3  Tibial and femoral tunnel

volumes after surgery and after
6 months and 2 years

point zero, but was comparable between the two groups after No significant differences were found in the IKDC subjec-
6 months and 2 years (not significant) (Table 3). tive score, Tegner activity score, or Lysholm score at the
In the group with button fixation, no significant differ- final follow-up (Table 4).
ences in the femoral tunnel volume change over time were
observed between the anteromedial and outside-in femoral
tunnel drilling techniques (Appendix, Table 2). Discussion

Tunnel location The most important finding of this study is that all-inside
ACL reconstruction using button fixation is associated with
The tunnel location was comparable between the two groups less postoperative tibial tunnel widening in comparison
on the tibial side (not significant). The centre of the femo- with interference screw fixation. The first hypothesis was
ral tunnel was located significantly more posteriorly with rejected, as the group with button fixation showed less tun-
screw fixation in comparison with button fixation (P = 0.004) nel widening on the tibial side. The second hypothesis was
(Table  2). The femoral tunnel location was comparable partly accepted, as screw fixation showed a trend toward less
between the anteromedial and outside-in femoral tunnel knee laxity in comparison with button fixation.
drilling techniques (not significant) (Appendix, Table 2). The aetiology of postoperative tunnel widening is still
not fully understood, but biomechanical and biological
Clinical outcome issues have been postulated. With button fixation, graft
micromovements at the bone–tendon interface (bungee,
At the final follow-up, 1 of 14 patients (7.1%) with screw windshield wiper effects) or synovial fluid migration into
fixation was graded C in the IKDC objective score, in com- the tunnel might cause tunnel widening. Initial bone tun-
parison with 5 of 16 patients (31.3%) with button fixation nel enlargement, bone and graft damage during insertion,
(not significant). Two of 14 patients (14.3%) with screw fixa- allergic reactions and biological or immune responses to
tion had KT laxity of more than 3 mm, in comparison with 7 the foreign material are concerns with the use of biodegrad-
of 16 patients (43.8%) with button fixation (not significant). able screws [9, 11, 21, 44]. In the present study, all-inside

Table 3  Maximal tunnel diameter

 Group (mm) N (%)
Postoperative 6 months 24 months  > 10 mm  > 12 mm

Tibial tunnel
 Screw 11.0 ± 0.9 12.3 ± 1.4 12.0 ± 1.6 14 (100%) 5 (35.7%)
 Button 8.1 ± 0.5 10.0 ± 1.1 9.2 ± 1.1 3 (18.8%) 0 (0%)
 P value  < 0.001  < 0.001  < 0.001  < 0.001 0.014
 Group (mm) N (%)
Postoperative 6 months 24 months  > 10 mm  > 12 mm

Femoral tunnel
 Screw 9.0 ± 0.6 11.1 ± 1.3 10.4 ± 1.6 8 (57.1%) 2 (14.3%)
 Button 7.8 ± 1.1 10.8 ± 1.6 9.7 ± 1.9 7 (43.8%) 3 (18.8%)
 P value 0.001 n.s n.s n.s n.s

Data are shown as mean with standard deviation

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Knee Surgery, Sports Traumatology, Arthroscopy

Table 4  Clinical outcome parameters and a larger proportion of patients may require bone tun-
Screw (n = 14) Button (n = 16) P value
nel filling. A comparable tunnel situation in terms of tunnel
diameter can be expected on the femoral side after screw
IKDC (No. of patients in A/B/C/D) or button fixation. The centre of the femoral tunnel was
 Preoperative 0/1/9/4 0/1/15/0 n.s located significantly more posteriorly with screw fixation in
 2 years 8/5/1/0 3/8/5/0 n.s comparison with button fixation for both the outside-in and
IKDC subjective medial portal drilling techniques. Our explanation for this
 Preoperative 61 ± 8 67 ± 17 n.s is that the femoral screw was inserted through the medial
 2 years 89 ± 10 88 ± 5 n.s portal anteriorly to the graft. This might lead to an initial
Pivot shift (0, glide +, clunk + +, gross + + +) tunnel expansion at the location of least resistance in the
 Preoperative 4/8/2/0 3/10/3/0 n.s posterior tunnel wall.
 2 years 13/1/0/0 12/3/1/0 n.s There are concerns regarding a higher graft failure rate
KT-1000 side-to-side difference (mm) with all-inside ACL reconstruction using adjustable-length
 Preoperative 3.4 ± 1.5 5.1 ± 2.6 0.025 loop cortical buttons in comparison with conventional
 2 years 1.4 ± 1.5 2.9 ± 2.6 n.s ACL reconstruction techniques [10]. Biomechanical analy-
Lysholm ses have shown large graft elongation for all-inside ACL
 Preoperative 73 ± 10 80 ± 15 n.s grafts with adjustable-length loop cortical button devices.
 2 years 94 ± 7 94 ± 5 n.s Mayr et al. [27] used porcine tibiae and bovine extensor
Tegner tendons to compare the all-inside graft preparation tech-
 Preinjury 7 (6–9) 7 (5–9) n.s nique with button fixation in comparison with conven-
 2 years 6 (3–9) 6 (3–9) n.s tional graft preparation with a femoral button and tibial
Single leg hop (% of uninjured leg) interference screw fixation. The authors reported greater
 Preoperative 69 ± 30 87 ± 13 n.s graft elongation during cyclic loading with all-inside graft
 2 years 99 ± 6 97 ± 10 n.s preparation with button fixation in comparison with the
Data are shown as mean ± standard deviation, median (range) graft with tibial interference screw fixation (6.0 ± 0.6 mm
IKDC International Knee Documentation Committee vs 3.3 ± 0.8 mm). Other studies have reported overall graft
elongation during cyclic loading of 5.98–6.1 mm for the
all-inside graft with two adjustable-length loop cortical
ACL reconstruction with button fixation was association buttons [28, 38]. Graft elongation may result from slippage
with less change in the tibial tunnel volume over 2 years in of the tendon strands at the securing sutures and from an
comparison with screw fixation. The change in the femo- increased distance of the fixation points when extracorti-
ral tunnel volume was comparable between the two study cal button fixation is used. Knee laxity with a side-to-side
groups. These results are consistent with the findings of a difference of more than 3 mm is a commonly used crite-
recent study by Monaco et al. [32] that reported more tibial rion for quantifying failure of ACL reconstruction [5, 41].
tunnel widening with ACL reconstruction using a tibial bio- In the present study, knee laxity with a more than 3 mm
degradable interference screw and femoral cortical button side-to-side difference was observed in more patients with
fixation in comparison with all-inside ACL reconstruction button fixation in comparison with screw fixation (2 of
with button fixation. CT measurements were performed 14 versus 7 of 16). Despite patient randomization, the
1 year after surgery. The authors reported a mean tibial group with button fixation had higher knee laxity values
diameter increase of 0.81 ± 0.41 mm in the middle tunnel preoperatively—a risk factor that has been reported for
portion and 0.79 ± 0.78 mm in the articular portion after all- postoperative laxity of more than 3 mm [6]. Bressy et al.
inside ACL reconstruction. For tibial screw fixation, a mean [8] reported a similarly high rate of residual side-to-side
tibial diameter increase of 2.42 ± 1.51 mm in the middle tun- differences of more than 3 mm in 16 of 35 patients (46%)
nel portion and 1.51 ± 0.81 mm in the articular portion was after all-inside ACL reconstruction using adjustable-
reported. The tunnel diameter is an important factor when length loop cortical button fixation on the femoral and
one is considering single-stage or two-stage revision ACL tibial sides. In a prospective randomized study, Lubowitz
surgery. With tunnel enlargement more than 10 mm in diam- et al. [24] compared all-inside ACL reconstruction with
eter, staged revision surgery must be considered and may be button fixation and ACL reconstruction with aperture
indicated at more than 12 mm [29, 41]. In the present study, interference screw fixation using a tibial screw placed in
significantly more patients with screw fixation had tibial tun- retrograde fashion [24]. They reported comparable scores
nel diameters larger than 10 or 12 mm in comparison with for knee stability and clinical outcome after 2 years. In the
button fixation. In revision surgery, larger tibial tunnels must retrospective study by Monaco et al. [32], comparable out-
be expected with the use of tibial interference screw fixation, come and knee laxity values between ACL reconstruction

13
 Knee Surgery, Sports Traumatology, Arthroscopy

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domized trial design, with longitudinal tunnel widening vol- 8. Bressy G, Brun V, Ferrier A, Dujardin D, Oubaya N, Morel N
ume assessment on CT scans. CT is the most accurate image et al (2016) Lack of stability at more than 12 months of follow-
modality for assessing tunnel widening after ACL recon- up after anterior cruciate ligament reconstruction using all-inside
quadruple-stranded semitendinosus graft with adjustable cortical
struction [26, 30]. The clinical relevance of this study is button fixation in both femoral and tibial sides. Orthop Traumatol
that ACL reconstruction with tibial button fixation results in Surg Res 102:867–872
smaller tunnels in comparison with screw fixation; this may 9. Buelow JU, Siebold R, Ellermann A (2002) A prospective evalu-
be advantageous if revision ACL reconstruction is required. ation of tunnel enlargement in anterior cruciate ligament recon-
struction with hamstrings: extracortical versus anatomical fixa-
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10. Connaughton AJ, Geeslin AG, Uggen CW (2017) All-inside ACL
reconstruction: how does it compare to standard ACL reconstruc-
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11. Emond CE, Woelber EB, Kurd SK, Ciccotti MG, Cohen SB
(2011) A comparison of the results of anterior cruciate ligament
All-inside ACL reconstruction using button fixation was reconstruction using bioabsorbable versus metal interference
associated with less tibial tunnel widening and smaller screws: a meta-analysis. J Bone Joint Surg Am 93:572–580
tunnels after 2 years in comparison with ACL reconstruc- 12. Fink C, Zapp M, Benedetto KP, Hackl W, Hoser C, Rieger M
(2001) Tibial tunnel enlargement following anterior cruciate liga-
tion using screw fixation. There were no significant dif- ment reconstruction with patellar tendon autograft. Arthroscopy
ferences in the clinical outcome between the two groups. 17:138–143
13. Glasbrenner J, Domnick C, Raschke MJ, Willinghofer T, Kittl C,
Acknowledgements  The authors are grateful to Clemens Unterwur- Michel P, et al. (2018) Adjustable buttons for ACL graft cortical
zacher for the illustrations. fixation partially fail with cyclic loading and unloading. Knee
Surg Sports Traumatol Arthrosc. https​://doi.org/10.1007/s0016​
Funding  Funding for the study was received from Arthrex Inc. 7-018-5262-2
14. Greenhouse SW, Geisser S (1959) On methods in the analysis of
Complaince with ethical standards  profile data. Psychometrika 24:95–112
15. Hoher J, Moller HD, Fu FH (1998) Bone tunnel enlargement after
anterior cruciate ligament reconstruction: fact or fiction? Knee
Conflict of ineterst  The corresponding author declares that all authors Surg Sports Traumatol Arthrosc 6:231–240
listed have no conflict of interest. 16. Inderhaug E, Strand T, Fischer-Bredenbeck C, Solheim E (2014)
Effect of a too posterior placement of the tibial tunnel on the out-
Ethical approval  IRB: Ethics committee Medical University Innsbruck come 10–12 years after anterior cruciate ligament reconstruction

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Knee Surgery, Sports Traumatology, Arthroscopy

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