Tibial bone plug resorption with extra-articular cyst: A rare complication of anterior cruciate ligament reconstruction

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<ul><li><p>Case Report </p><p>Tibial Bone Plug Resorption With Extra-Articular Rare Complication of Anterior Cruciate </p><p>Ligament Reconstruction </p><p>Cyst: A </p><p>David Brettler, M.D., and Michael Soudry, M.D. </p><p>Summary: Anterior cruciate ligament (ACL) reconstruction failure resulted in fibial bone plug resorption and the formation of a large extra-articular cyst. To our knowledge, this is the first report of this kind of ACL failure. The relationship to known factors is discussed. Key Words: Anterior cruciate ligament--Bone plug resorption--Cyst formation. </p><p>A nterior cruciate ligament (ACL) reconstruction with the use of a patella bone-tendon-bone graft is a common procedure. ~3 It restores function and sta- bility in the majority of patients. However, joint com- plications following ligament reconstruction, are not uncommon. 4 Joint effusion, quadriceps weakness, pa- tellofemoral pain, 5 and joint stiffness 6"7 have been re- ported. </p><p>Analysis of ACL failure has emphasized biome- chanical problems, such as poor graft strength, s poor fixation, 9 impingement by the femoral notch, ~ and poor rehabilitation. 1~ However, we have relatively in- adequate knowledge of the healing biology inside the bony tunnel. ~z </p><p>We present a rare complication of ACL reconstruc- tion that resulted in bone plug and tunnel wall resorp- tion. This was also associated with the formation of a large extra-articular cyst that originated from the exter- </p><p>From the Shoulder and Arthroscopy Service, the Center for Im- plant Surgery, Bnei Zion Medical Center, Haifa, Israel; and the department of Orthopaedic Surgery, Western Galilee Medical Cen- ter, Nahariya, Israel. </p><p>Address correspondence and reprint request to David Brettler, M.D., Bnei Zion Medical Center, P.O.B. 4940, Haifa 31048, Israel. </p><p> 1995 by the Arthroscopy Association of North America 0749-8063/95/1104-122253.00/0 </p><p>nal opening of the tibial tunnel and was communicating with the joint space. </p><p>CASE REPORT </p><p>A 41-year-old male clerk, A. N., injured his right knee while participating in karate, in March 1991. He was admitted to Bnei Zion Medical Center where he underwent evaluation and was found to have 2+ me- dial instability, 3 + Lachman, and 3 + ALRI test results. At arthroscopy, a complete ACL tear was confirmed. The patient underwent ACL reconstruction with the use of the middle third patella bone-tendon-bone auto- graft. </p><p>On follow-up 1 year following surgery, the patient complained of anterior knee pain. On examination, he was found to flex to 130 with a 10 lack of extension. For his normal left knee, motion was 0 to 140 . Also, 2 cm of quadriceps atrophy was noted. The patient resumed his normal activities including exercise; how- ever, he did not return to karate. </p><p>Eighteen months following his original injury and surgery, the patient was seen in the office with a com- plaint of pain over a large cystic mass at the level of the tibial tunnel opening (Figs 1 and 2). An aspiration of the cyst was performed that yielded clear fluid Fig </p><p>478 Arthroscopy.- The Journal o f Arthroscopic and Related Surgery, Vol 11, No 4 (August), 1995." pp 478-481 </p></li><li><p>TIBIAL BONE PLUG RESORPTION WITH CYST 479 </p><p>ing from tibial tunnel, with clear synovial fluid inside. The screw in the tunnel was found to be loose, and the tunnel itself quite enlarged. No bone plug material could be detected. </p><p>Postoperatively, the patient did well. At his most recent follow-up examination, 1 years following his repeat arthroscopy, he returned to regular activity in- cluding recreational sports. His patellofemoral pain re- </p><p>FIG 1. Knee in flexion showing large cyst over the tibial tunnel. </p><p>3. With the assumption that this cyst may represent a bursa over the metal hardware, an injection of 1 mL celestone chronodose into the lesion provided tempo- rary relief for several mouths. However, later on, he experienced again knee pain and swelling. </p><p>Three months later he was admitted for an arthros- copy and removal of the cyst. Roentgenograms at that time showed enlargement of the original 10-mm tibial tunnel (Fig 3). </p><p>Arthroscopic evaluation of the knee showed sig- nificant infrapatellar adhesions. Both menisci were intact, the articular cartilage of the tibiofemoral ar- ticulation and the patellofemoral joint were found to be normal. An injection of methylene blue to the cyst showed that the dye rapidly appeared inside the knee joint. </p><p>The infrapatellar area was debrided arthroscopically and the cyst was excised through the previous skin incision over the tibia. The cyst was 5 8 cm, originat- FIG 2. Cyst during extension, also note extension lag. </p></li><li><p>480 D. BRETTLER AND M. SOUDRY </p><p>solved. On examination, the range of motion of the knee returned to normal, regaining full extension. He demonstrated a 1 + Lachman, negative rotatory insta- bility test, and no quadriceps atrophy. No recurrence of the cyst was noted. </p><p>DISCUSSION </p><p>FIG 3. (A) Anterior-posterior radiograph of the knee showing large cystic area around the tibial bone screw. (B) Lateral radiograph of the knee showing clearly the tibial tunnel enlargement. </p><p>ACL ligament reconstruction with the use of patellar bone-tendon-bone graft is a common procedure with satisfactory results. 13'14 The main reasons for failure are technical, mainly inaccurate tunnel placement, and impingement against the femoral notch. This may con- tribute to extension lag, and also to patellofemoral problems. Howell et al. 15 have shown that too exces- sive anterior positioning may result in edematous high- intensity signal on magnetic resonance imaging. There has been a report of ACL failure resulting from bone- plug nonunion, as a possible result of notch impinge- ment and pull on the plug. 16 </p><p>In our case, the patient suffered from pateUofemoral symptoms, associated with 10 of flexion contracture. Approximately 18 months following his ACL recon- struction, he developed a large cystic lesion at the ex- ternal opening of the tibial tunnel that was communi- cating with the knee joint. This was associated with complete resorption of the bone plug, and also bone resorption at the level of the tunnel wall. </p><p>It may well be that intra-articular joint fluid had dissected under pressure along the tibial tunnel. This may have provoked nonunion and resorption of the graft, with formation of large extra-articular cyst. This mechanism is the same one involved in the formation of large popliteal or Baker cysts. I7'1s </p><p>It is possible that this entity developed because of anterior placement of the graft with resulting impinge- ment by the notch, and the development of flexion contracture. The chronic irritation, with continuous se- cretion of synovial fluid, resulted in increased intra- articular pressure and bone plug failure, including its resorption. It is interesting to note that, following de- bridement of the infrapatellar area from adhesions and remaining soft tissue, knee irritation had stopped. No recurrence of the cyst was noted. </p><p>This case shows that careful attention to technical details are extremely important while performing ACL reconstruction. Failure of the bone plug to unite and creation of a large cyst may have resulted in this case from chronic knee irritation with leakage of synovial fluid to the tunnel and outside the knee. </p></li><li><p>T I B I A L B O N E P L U G R E S O R P T I O N W I T H C Y S T 481 </p><p>REFERENCES </p><p>1. Clancy WG, Nelson DA, Reider B, Narechnania RG. Anterior cruciate ligament reconstruction using one third of the patella lig, augmented by extra articular tendon transfer. J Bone Joint Surg Am 1982;64:352-359. </p><p>2. O'Brien SJ, Warren RF, Parlor H, Panariello R, Wickiewicz TL. Reconstruction of chronically insufficient anterior cruciate ligament. J Bone Joint Surg Am 1991;73:278-286. </p><p>3. Tibone JE, Antich TJ. A biomechanical analysis of anterior cruciate ligament reconstruction with patellar tendon: Two-year follow-up. Am J Sports Med 1980; 16:332-335. </p><p>4. Sachs RA, Reznick A, Daniel DM, Stone ML. Complication of knee ligament surgery. In: Daniel DM, Akeson W, O'Conner J, eds. Knee ligaments structure function, injury and repair. New York: Raven, 1990. </p><p>5. Sachs RA, Daniel DM, Stone ML, Garfein RF. Patetlofemoral problems after ACL reconstruction. Am J Sport Med 1989; 17:760-765. </p><p>6. Parisien JS. The role of arthroscopy in the treatment of post operative fibroarthrosis of the knee joint. Clin Orthop 1988;229:185-192. </p><p>7. Sprague NF III, O'Conner RL, Fox JM. Arthroscopic treatment of postoperative knee fibroarthrosis. Clin Orthop 982; 166:165- 172. </p><p>8. Noyes FR, Butler DL, Grood ES, Zeruicke RF, Hefzy MS. 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