Reduction of Tunnel Enlargement With Use of Autologous Ruptured Tissue in Anterior Cruciate Ligament Reconstruction: A Pilot Clinical Trial

Published:February 27, 2014DOI:


      To compare the tunnel enlargement of double-bundle (DB) anterior cruciate ligament reconstruction (ACLR) with and without suturing of autologous ruptured tissue to hamstring graft in patients with subacute anterior cruciate ligament injury.


      Ten patients with subacute (≤3 months after injury) anterior cruciate ligament rupture were randomly allocated to undergo DB ACLR with suturing of the ruptured tissue to hamstring graft (n = 5) or conventional DB ACLR (n = 5). When autologous ruptured tissue was used, remnant ruptured tissue was then harvested, divided into 4 pieces, placed between the loops at the distal and proximal portions of the graft, and secured with the suture. As the primary endpoint, tunnel volume assessment by 3-dimensional multi–detector row computed tomography (MDCT) was performed 1 year after ACLR. To assess the efficacy of these procedures, the Lysholm score, anterior tibial translation (measured with a KT-1000 arthrometer [MEDmetric, San Diego, CA]), and rotational instability (measured by the pivot-shift test) were evaluated after 2 years.


      Tunnel volume enlargement between 3 weeks and 1 year after ACLR as assessed by 3-dimensional MDCT was significantly less for ACLR using ruptured tissue than for conventional ACLR, especially at the femoral site (P < .05). However, the postoperative Lysholm score, anterior stability of the knee measured with the KT-1000 arthrometer, and rate of negative manual pivot-shift test results did not differ significantly between the 2 groups. There was no correlation to the clinical outcomes in terms of tunnel size.


      The Lysholm score, anterior laxity measured with the KT-1000 arthrometer, and rotational instability according to the pivot-shift test did not differ significantly between ACLR using ruptured tissue and the conventional technique. However, ACLR using ruptured tissue produced less femoral tunnel enlargement as assessed by MDCT, warranting further long-term follow-up to elucidate its effectiveness.

      Level of Evidence

      Level II, prospective comparative study.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bach Jr., B.R.
        • Tradonsky S.
        • Bojchuk J.
        • Levy M.E.
        • Bush-Joseph C.A.
        • Khan N.H.
        Arthroscopically assisted anterior cruciate ligament reconstruction using patellar tendon autograft. Five- to nine-year follow-up evaluation.
        Am J Sports Med. 1998; 26: 20-29
        • Beynnon B.D.
        • Johnson R.J.
        • Fleming B.C.
        • et al.
        Anterior cruciate ligament replacement: Comparison of bone-patellar tendon-bone grafts with two-strand hamstring grafts. A prospective, randomized study.
        J Bone Joint Surg Am. 2002; 84: 1503-1513
        • Aglietti P.
        • Giron F.
        • Buzzi R.
        • Biddau F.
        • Sasso F.
        Anterior cruciate ligament reconstruction: Bone-patellar tendon-bone compared with double semitendinosus and gracilis tendon grafts. A prospective, randomized clinical trial.
        J Bone Joint Surg Am. 2004; 86: 2143-2155
        • Fauno P.
        • Kaalund S.
        Tunnel widening after hamstring anterior cruciate ligament reconstruction is influenced by the type of graft fixation used: A prospective randomized study.
        Arthroscopy. 2005; 21: 1337-1341
        • L'Insalata J.C.
        • Klatt B.
        • Fu F.H.
        • Harner C.D.
        Tunnel expansion following anterior cruciate ligament reconstruction: A comparison of hamstring and patellar tendon autografts.
        Knee Surg Sports Traumatol Arthrosc. 1997; 5: 234-238
        • Ekdahl M.
        • Nozaki M.
        • Ferretti M.
        • Tsai A.
        • Smolinski P.
        • Fu F.H.
        The effect of tunnel placement on bone-tendon healing in anterior cruciate ligament reconstruction in a goat model.
        Am J Sports Med. 2009; 37: 1522-1530
        • Getelman M.H.
        • Friedman M.J.
        Revision anterior cruciate ligament reconstruction surgery.
        J Am Acad Orthop Surg. 1999; 7: 189-198
        • Petrigliano F.A.
        • McAllister D.R.
        • Wu B.M.
        Tissue engineering for anterior cruciate ligament reconstruction: A review of current strategies.
        Arthroscopy. 2006; 22: 441-451
        • Chen C.H.
        • Chen W.J.
        • Shih C.H.
        • Yang C.Y.
        • Liu S.J.
        • Lin P.Y.
        Enveloping the tendon graft with periosteum to enhance tendon-bone healing in a bone tunnel: A biomechanical and histologic study in rabbits.
        Arthroscopy. 2003; 19: 290-296
        • Karaoglu S.
        • Celik C.
        • Korkusuz P.
        The effects of bone marrow or periosteum on tendon-to-bone tunnel healing in a rabbit model.
        Knee Surg Sports Traumatol Arthrosc. 2009; 17: 170-178
        • Lim J.K.
        • Hui J.
        • Li L.
        • Thambyah A.
        • Goh J.
        • Lee E.H.
        Enhancement of tendon graft osteointegration using mesenchymal stem cells in a rabbit model of anterior cruciate ligament reconstruction.
        Arthroscopy. 2004; 20: 899-910
        • Huangfu X.
        • Zhao J.
        Tendon-bone healing enhancement using injectable tricalcium phosphate in a dog anterior cruciate ligament reconstruction model.
        Arthroscopy. 2007; 23: 455-462
        • Sasaki K.
        • Kuroda R.
        • Ishida K.
        • et al.
        Enhancement of tendon-bone osteointegration of anterior cruciate ligament graft using granulocyte colony-stimulating factor.
        Am J Sports Med. 2008; 36: 1519-1527
        • Yoshikawa T.
        • Tohyama H.
        • Katsura T.
        • et al.
        Effects of local administration of vascular endothelial growth factor on mechanical characteristics of the semitendinosus tendon graft after anterior cruciate ligament reconstruction in sheep.
        Am J Sports Med. 2006; 34: 1918-1925
        • Rodeo S.A.
        • Suzuki K.
        • Deng X.H.
        • Wozney J.
        • Warren R.F.
        Use of recombinant human bone morphogenetic protein-2 to enhance tendon healing in a bone tunnel.
        Am J Sports Med. 1999; 27: 476-488
        • Zheng B.
        • Cao B.
        • Crisan M.
        • et al.
        Prospective identification of myogenic endothelial cells in human skeletal muscle.
        Nat Biotechnol. 2007; 25: 1025-1034
        • Howson K.M.
        • Aplin A.C.
        • Gelati M.
        • Alessandri G.
        • Parati E.A.
        • Nicosia R.F.
        The postnatal rat aorta contains pericyte progenitor cells that form spheroidal colonies in suspension culture.
        Am J Physiol Cell Physiol. 2005; 289: C1396-C1407
        • Zengin E.
        • Chalajour F.
        • Gehling U.M.
        • et al.
        Vascular wall resident progenitor cells: A source for postnatal vasculogenesis.
        Development. 2006; 133: 1543-1551
        • Matsumoto T.
        • Ingham S.M.
        • Mifune Y.
        • et al.
        Isolation and characterization of human anterior cruciate ligament-derived vascular stem cells.
        Stem Cells Dev. 2012; 21: 859-872
        • Mifune Y.
        • Matsumoto T.
        • Ota S.
        • et al.
        Therapeutic potential of anterior cruciate ligament-derived stem cells for anterior cruciate ligament reconstruction.
        Cell Transplant. 2012; 21: 1651-1665
        • Matsumoto T.
        • Kubo S.
        • Sasaki K.
        • et al.
        Acceleration of tendon-bone healing of anterior cruciate ligament graft using autologous ruptured tissue.
        Am J Sports Med. 2012; 40: 1296-1302
        • Araki D.
        • Kuroda R.
        • Kubo S.
        • et al.
        A prospective randomised study of anatomical single-bundle versus double-bundle anterior cruciate ligament reconstruction: Quantitative evaluation using an electromagnetic measurement system.
        Int Orthop. 2011; 35: 439-446
        • Iorio R.
        • Vadala A.
        • Argento G.
        • Di Sanzo V.
        • Ferretti A.
        Bone tunnel enlargement after ACL reconstruction using autologous hamstring tendons: A CT study.
        Int Orthop. 2007; 31: 49-55
        • Brown Jr., C.H.
        • Wilson D.R.
        • Hecker A.T.
        • Ferragamo M.
        Graft-bone motion and tensile properties of hamstring and patellar tendon anterior cruciate ligament femoral graft fixation under cyclic loading.
        Arthroscopy. 2004; 20: 922-935
        • Hoher J.
        • Moller H.D.
        • Fu F.H.
        Bone tunnel enlargement after anterior cruciate ligament reconstruction: Fact or fiction?.
        Knee Surg Sports Traumatol Arthrosc. 1998; 6: 231-240
        • Gabriel M.T.
        • Wong E.K.
        • Woo S.L.
        • Yagi M.
        • Debski R.E.
        Distribution of in situ forces in the anterior cruciate ligament in response to rotatory loads.
        J Orthop Res. 2004; 22: 85-89
        • Robert H.
        • Es-Sayeh J.
        The role of periosteal flap in the prevention of femoral widening in anterior cruciate ligament reconstruction using hamstring tendons.
        Knee Surg Sports Traumatol Arthrosc. 2004; 12: 30-35
        • Li H.
        • Jiang J.
        • Wu Y.
        • Chen S.
        Potential mechanisms of a periosteum patch as an effective and favourable approach to enhance tendon-bone healing in the human body.
        Int Orthop. 2012; 36: 665-669
        • Chen C.H.
        • Chang C.H.
        • Su C.I.
        • et al.
        Arthroscopic single-bundle anterior cruciate ligament reconstruction with periosteum-enveloping hamstring tendon graft: Clinical outcome at 2 to 7 years.
        Arthroscopy. 2010; 26: 907-917
        • Adachi N.
        • Ochi M.
        • Uchio Y.
        • Iwasa J.
        • Ryoke K.
        • Kuriwaka M.
        Mechanoreceptors in the anterior cruciate ligament contribute to the joint position sense.
        Acta Orthop Scand. 2002; 73: 330-334
        • Ochi M.
        • Abouheif M.M.
        • Kongcharoensombat W.
        • Nakamae A.
        • Adachi N.
        • Deie M.
        Double bundle arthroscopic anterior cruciate ligament reconstruction with remnant preserving technique using a hamstring autograft.
        Sports Med Arthrosc Rehabil Ther Technol. 2011; 3: 30
        • Yasuda K.
        • Kondo E.
        • Kitamura N.
        • Kawaguchi Y.
        • Kai S.
        • Tanabe Y.
        A pilot study of anatomic double-bundle anterior cruciate ligament reconstruction with ligament remnant tissue preservation.
        Arthroscopy. 2012; 28: 343-353
      1. Ochi M, Adachi N, Deie M, Kanaya A. Anterior cruciate ligament augmentation procedure with a 1-incision technique: Anteromedial bundle or posterolateral bundle reconstruction. Arthroscopy 2006;22:463.e1-463.e5. Available online at

        • Ochi M.
        • Adachi N.
        • Uchio Y.
        • et al.
        A minimum 2-year follow-up after selective anteromedial or posterolateral bundle anterior cruciate ligament reconstruction.
        Arthroscopy. 2009; 25: 117-122