Soft Tissue Tendon Graft Fixation in Serially Dilated or Extraction-Drilled Tibial Tunnels

Dunkin, Brad S.; Nyland, John; Duffee, Andrew R.; Brunelli, Jeffrey A.; Burden, Robert; Caborn, David N.M.

doi:10.1177/0363546506294359

Cited by 21 publications

(8 citation statements)

References 56 publications

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“…The results of Dunkin et al [8] and Duffee et al [7] are in line with the study of Nurmi et al They used a porcine model. Twenty specimens in total underwent either serial dilation or extraction drilling.…”

Section: Discussionsupporting

confidence: 78%

Serial dilation versus extraction drilling in anterior cruciate ligament reconstruction: a biomechanical study

Sørensen

Jakobsen²,

Kold

et al. 2009

Knee Surg Sports Traumatol Arthrosc

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The hamstring tendon graft has become increasingly popular in anterior cruciate ligament reconstruction because of low donor-site morbidity. However, the tibial fixation is considered difficult, mainly because of low tibial mineral bone density. Therefore, we tested whether preparation of the tibial tunnel with compaction by serial dilation provided a stronger anchorage of the graft-fixation-device complex than does traditional extraction drilling of the tibial tunnel. In 20 bovine tibiae, the bone tunnels were created with either extraction drilling (group 1) or compaction by serial dilation (group 2). Twenty bovine digital extensor tendons were fixated in the bone tunnel with an Intrafix tibial fastener. The graft-fixation-device complexes were mounted in a hydraulic test machine. The fixation strength was evaluated after cyclic loading. The difference between the serial dilation group and the extraction drilling group ranged from a mean slippage of 0 mm at 70-220 N, to a mean slippage of 0.1 mm at 70-520 N. We found no significant difference in slippage of the graft-fixation-device complex after 1,600 cycles. This study failed to show a significant difference between compaction by serial dilation and extraction drilling of the tibia bone tunnel in anterior cruciate ligament reconstruction.

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Section: Discussionsupporting

confidence: 78%

Serial dilation versus extraction drilling in anterior cruciate ligament reconstruction: a biomechanical study

Sørensen

Jakobsen²,

Kold

et al. 2009

Knee Surg Sports Traumatol Arthrosc

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“…In early stages of rehabilitation following ACL reconstruction, the loading on the knee would model closer to a cyclic test than an ultimate failure load. 3 , 10 , 12 The cyclic loading results show that failure load and peak stress did not decrease with an increase in the number of cycles. The data also show that elongation increased as the cycle count increased, which is expected as longer time under stress should stretch the tendon length.…”

Section: Discussionmentioning

confidence: 92%

Comparison of Pull-out Strength for Different Bone Block Length in a Porcine Anterior Cruciate Ligament Model

Posner

Owens

Johnson

et al. 2014

Orthopaedic Journal of Sports Medicine

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Background:Bone block length for bone–patellar tendon–bone (BPTB) anterior cruciate ligament (ACL) reconstruction has traditionally been 25 mm in length. The previous surgical technique did not require the surgeon to pay particular attention to the length of the bone block, and therefore, there is scant evidence in the literature describing ideal lengths. With the gaining popularity of accessory medial portal drilling of the femoral tunnel, concerns with tunnel length and graft shuttling have surfaced. Newer techniques have advised shortening of the femoral bone block to accommodate the shorter tunnel and for ease of bone block manipulation into the aperture of the tunnel.Purpose:To compare the effects of bone block length on the pull-out strength of patellar tendon grafts using metal interference screws in a porcine ACL reconstruction model. The hypothesis was that the pull-out strength of each length of bone block under cyclic and ultimate load to failure testing would surpass the physiologic loads experienced by a normal ACL.Study Design:Controlled laboratory study.Methods:This study used 27 unmatched porcine femurs and BPTB constructs. Specimens were randomly assigned to a 10-, 15-, or 20-mm bone block reconstruction and a cycle load of 100, 500, or 1000 cycles. This resulted in 9 specimen groups with 3 specimens in each group. A central composite design (CCD) for the test matrix was selected, as this was optimum for requiring relatively few experiments while still exploring the complete range of interest for 2 independent variables. Each reconstruction used a 7 × 20–mm titanium interference screw. All reconstructions were performed on the femoral side using 10-mm-wide patellar tendon grafts, and tensile tests were performed. The loading protocol started with a 20-N preload, then cyclic testing to the appropriate number of cycles in the elastic region between 50 and 150 N at a strain rate of 200 mm/min, and then ended with ultimate load-to-failure testing. Ultimate load to failure, peak stress, elongation, and stiffness were all recorded. The patellar tendon graft mode of failure was measured by visual inspection.Results:During load-to-failure testing, 5 of 9 graft constructs in the 10-mm group failed at the bone block, while 2 of 9 failed in the 15-mm group at this interface. In the 20-mm group, all 9 specimens failed at the tendon, and none failed at the bone block. There was a statistically significant difference in modes of failure between the bone block length groups in the reconstructed ACL grafts. Analysis indicates that a smaller bone block length graft is more likely to fail due to a bone block failure than a tendon failure. The average ± standard deviation failure load for all specimens was 573 ± 171 N. The mean failure loads for the 10-, 15-, and 20-mm groups were 614 ± 110, 658 ± 92, and 540 ± 203 N, respectively. There was no statistical significance between the groups in any of these measurements.Conclusion:Bone blocks of 20 to 25 mm in length are normally used in surgical practice. Thus, the pu...

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“…Absence of statistical difference continues from human clinical and biomechanical cadaveric data into animal models comparing ED and SD. Results from porcine tibiae models of ED and SD demonstrate that the two techniques do not result in statistically significant differences regarding fixation strength of the grafts (25–27). These results from porcine tibiae models differ from the biomechanical results, suggesting that SD performs better than ED by increasing the overall force required to initiate graft failure.…”

Section: Discussionmentioning

confidence: 94%

No difference between extraction drilling and serial dilation for tibial tunnel preparation in anterior cruciate ligament reconstruction: a systematic review

Crum

Ayeni

et al. 2018

Journal of ISAKOS

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Importance: This review highlights a lack of consensus and need for further study regarding optimal tibial tunnel preparation method in anterior cruciate ligament reconstruction (ACLR). Objective: This review examines existing clinical and biomechanical outcomes of both extraction drilling (ED) and serial dilation (SD) as a technique for tibial tunnel preparation in ACLR. Evidence Review: In accordance with PRISMA guidelines, three electronic databases (MEDLINE, EMBASE, and PubMed) were searched and systematically screened in duplicate from database inception to September 6, 2017 for English-language, human studies, of all levels of evidence that examined ED and/or SD for tibial tunnel preparation in ACLR. Data including patient demographics, tibial tunnel preparation techniques, biomechanical and clinical outcomes and complications were retrieved from eligible studies. Findings: ED was used in 71 patients, who were mean age 29.9 years (range: 17–50), 68% male, and followed for mean 16.5 months (range: 3.8–46). SD was used in 70 patients (70 knees), who were mean age 29.3 years (range: 18–50), 69% male, and followed for mean 14.1 months (range: 3.8–46). There were no statistically significant differences (mean preoperative; mean postoperative) for either tibial preparation technique for Lysholm (50.1; 92.5), Tegner (3.5; 6.1), International Knee Documentation Committee (IKDC) (48.8; 92.7), and Lachman or laxity scores. However, ED demonstrated statistically significant increased postoperative tibial tunnel expansion (1.8 mm versus 1.4 mm) and (at 12 weeks) graft migration at the tibial fixation site (1.3 mm versus 0.8 mm). Across biomechanical studies, there were no statistically significant differences (ED; SD) with forces required to initiate graft slippage (156 N; 174 N), graft stiffness (187 N; 186.5 N), and screw torque (1.6 N/m; 1.8 N/m). ED demonstrated a lower mean load to failure for the graft construct (433 N versus 631 N; p<0.05). Conclusions and Relevance: Though biomechanical data demonstrated lower mean load to failure for the graft using ED, clinical data suggest increased tibial tunnel expansion and post-operative graft migration at the tibial fixation site. Future studies with long-term follow-up data are required to ascertain the optimal technique for graft incorporation and postoperative success. Level of Evidence: IV:Systematic Review of Level I-IV studies.

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Soft Tissue Tendon Graft Fixation in Serially Dilated or Extraction-Drilled Tibial Tunnels

Abstract: Screw alignment plays a greater role in anterior cruciate ligament graft fixation than does extraction drilling or step dilation tunnel preparation methods in healthy bone.

Cited by 21 publications

References 56 publications

Serial dilation versus extraction drilling in anterior cruciate ligament reconstruction: a biomechanical study

Serial dilation versus extraction drilling in anterior cruciate ligament reconstruction: a biomechanical study

Comparison of Pull-out Strength for Different Bone Block Length in a Porcine Anterior Cruciate Ligament Model

No difference between extraction drilling and serial dilation for tibial tunnel preparation in anterior cruciate ligament reconstruction: a systematic review

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