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 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, three electronic databases (MEDLINE, Embase and PubMed) were searched and systematically screened in duplicate from database inception to 6 September 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, with mean age 29.9 years (range: 17–50 years), 68% male and followed for mean 16.5 months (range: 3.8–46 months). SD was used in 70 patients (70 knees), with mean age 29.3 years (range: 18–50 years), 69% male and followed for mean 14.1 months (range: 3.8–46 months). 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 (48.8; 92.7) and Lachman or laxity scores. However, ED demonstrated statistically significant increased postoperative tibial tunnel expansion (1.8 mm vs 1.4 mm) and (at 12 weeks) graft migration at the tibial fixation site (1.3 mm vs 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 vs 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 postoperative 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.
- acl / pcl
- repair / reconstruction
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Contributors RJC and DdS assisted with study design, data abstraction and analysis, and manuscript preparation. ORA and VM assisted with study design and manuscript preparation and review.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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