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Pretibial cyst formation after arthroscopic anterior cruciate ligament reconstruction
Case Report
Pretibial Cyst Formation After Arthroscopic Anterior Cruciate Ligament Reconstruction Omer A. Ilahi, M.D., Shiraz A. Younas, M.D., and Irvin K. Sahni, M.D.
Abstract: Pretibial cyst formation is a rare occurrence after anterior cruciate ligament (ACL) reconstruction. We report this complication after ACL reconstruction using a hamstring autograft. Bone grafting of the original tibial tunnels during revision surgeries after failed ACL reconstruction could prevent this rare complication. Key Words: ACL reconstruction—Cyst—Ganglion—Hamstring.
A
rthroscopic reconstruction of the anterior cruciate ligament (ACL) using autograft or allograft is commonly performed, and results, including stability and functioning, have been satisfactory.1-5 Complications are few and include stiffness, quadriceps weakness, bleeding, swelling, and infection.3 Synovial cyst formation is a rare complication after ACL reconstruction.6-10 However, researchers have suggested that revision surgeries pose a greater risk of synovial cyst formation due to the presence of multiple tunnels.7 Although studies have reported synovial ganglion formation after primary ACL reconstruction using hamstring grafts, there is a dearth of reports of this complication after a revision ACL reconstruction. The authors report formation of a pretibial synovial cyst after revision ACL reconstruction. CASE REPORT A 27-year-old woman presented with complaints of pain in the inferomedial aspect of her left knee. She
From the Department of Orthopedics, Baylor College of Medicine, Houston, Texas, U.S.A. Address correspondence and reprint requests to Omer A. Ilahi, M.D., 6560 Fannin, Suite 1016, Houston, TX. 77030, U.S.A. Email: [email protected] © 2003 by the Arthroscopy Association of North America 1526-3231/03/1902-3181$30.00/0 doi:10.1053/jars.2003.50045
had injured her ACL while playing soccer and underwent ACL reconstruction using a hamstring autograft in 1991. She did well after that surgery, regaining full range of motion and returning to sports. However, in 1998, she tore the reconstructed ligament while playing racquetball. She underwent an ACL revision surgery using a bone–patellar tendon– bone (BPTB) allograft with use of a 2-incision technique. At the time of revision, a separate tibial tunnel was drilled. No bone grafting of the tibial tunnel from the first reconstruction was performed. Afterward, the patient again regained full motion and returned to sports. One year after the revision procedure, the patient presented with new onset of a painful limp. There was tenderness localized to the area of insertion of an interference screw in the left tibia. The patient reported activity-related swelling in this area. Left knee range of motion was equal to the right knee: from 10° of hyperextension to 135° of flexion. The knee was stable, with negative Lachman’s and pivot shift tests. Radiographs revealed that tibial and femoral metallic interference screws were in place, with the tunnels in good position. The pain and swelling were thought to be because of irritation from the prominent tibial interference screw resulting in intermittent bursitis. Because of continuing symptoms, the patient elected to undergo elective removal of hardware. At surgery, examination under anesthesia revealed a stable knee with no effusion. KT-1000 measurements showed manual maximum excursion of 13 mm on the
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 2 (February), 2003: E5
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left and 11.5 mm on the right knee, indicating competent graft function. Arthroscopic examination revealed a viable ACL graft with good tension. Some fraying of the anterior fibers was noted. The femoral trochlear notch had some regrowth of cartilage along the margins. In addition, areas of chondromalacia on the medial femoral condyle and the patella were seen. The frayed fibers were debrided using a motorized shaver. After removing the arthroscopic instruments, a cystic palpable mass was identified over the proximal aspect of the tibia in the area of previous incisions. A 3-cm incision was created over the area of localized swelling medial to the tibial tubercle. A cystic mass was encountered and carefully dissected away from the surrounding subcutaneous tissue (Fig 1). The mass was incised, and a clear gelatinous material was seen, indicating the mass to be a ganglion cyst. The cyst was excised intact. There was a stalk that tracked into a hole in the proximal tibia, which could be traced back to the knee joint just anterior to the tibial insertion of the ACL graft. This tunnel was carefully curetted to remove any soft tissue and gelatinous material. The interference screw itself was seen to be just distal to this tunnel and was removed, leaving a small tunnel. Both tunnels were probed with radio-opaque instruments to determine the tunnel depths. The proximal tunnel was large enough to allow a hemostat to pass directly into the knee joint, just anterior to the ACL graft. The more distal tunnel was a blind tunnel created by removal of the interference screw (Fig 2). Both tunnels were packed with lyophilized bone graft. Arthroscopy was performed to insure that no bone graft extruded into the joint.
FIGURE 2. Intraoperative lateral radiograph of the knee with instruments in the proximal and distal tunnels. The curette is inserted into the tunnel created during the initial ACL reconstruction. The hemostat is inserted into the tunnel created by removing the interference screw used for tibial fixation of the revision procedure.
The cyst and gelatinous material were sent for pathologic examination, which revealed fibrous tissue containing multiple cystic spaces lacking an epithelial lining and containing myxoid material consistent with a ganglion cyst. No acute or chronic inflammation was found on microscopic examination. On last follow-up, 2 months after surgery, the patient was doing well and had not developed a recurrence of the synovial cyst. She was walking without a limp and had regained full range of motion with no knee instability. DISCUSSION
FIGURE 1. cyst.
Intraoperative photograph of the pretibial synovial
Various investigations have evaluated the occurrence of complications after arthroscopic ACL reconstruction. One study conducted in Japan followed 89 patients using magnetic resonance imaging (MRI) to
PRETIBIAL CYST FORMATION detect pretibial cysts as complications after ACL reconstruction using semitendinosus-gracilis grafts. They found cysts in 2 patients, a rate of 2.2%. The authors concluded that cyst formation occurred as a result of tendon necrosis during the process of incorporation into the osseous tunnel at 6 to 12 months.6 Some researchers have suggested that using a bone plug in ACL reconstruction decreases the risk of postoperative synovial cyst formation. Reports of cyst formation after hamstring reconstruction seem to be more common than after BPTB reconstructions. Simonian et al.7 reported 3 cases of pretibial ganglion formation after ACL reconstruction using hamstring grafts and 1 after ACL reconstruction using the iliotibial tract. Those authors reported no cases of cyst formation in those patients in whom a graft with a bone plug was used. Debridement and bone grafting successfully resolved the problem in the 3 patients symptomatic enough to warrant surgical treatment.7 Brettler and Soudry11 reported a case of pretibial cyst formation after use of a BPTB autograft in a 41-year-old man. This complication developed about 18 months after ACL reconstruction and was associated with enlargement of the tibial tunnel with loosening of the interference screw. Those authors concluded that the cyst developed as a result of excessive irritation due to femoral notch impingement that allowed synovial fluid to dissect down the graft under pressure, leading to resorption and failure of the bone plug. Victoroff et al.8 reported 3 cases of pretibial cyst formation after use of a patellar tendon allograft without a bone plug. They also reported 1 case of pretibial cyst formation in a patient in whom a hamstring graft was used without a bone plug. The authors recommended the use of bone plugs to avoid this complication. Martinek and Friederich10 reported a case in which a 32-year-old man developed an osteolytic cyst in the tibial tunnel with resorption of the bone plug after use of a poly-D,L-lactide interference screw. Those authors concluded that the cyst formation was a complication related to use of the poly-D,L-lactide interference screw. A later clinical trial on a new polygluconate interference screw reported 1 case of subcutaneous cyst formation in 124 patients who underwent ACL reconstruction with a BPTB autograft and this bioabsorbable interference screw.12 Also, Feldmann and Fanelli9 reported 1 case of a synovial cyst originating from the femoral tunnel. Nonabsorbable suture left in the graft was thought to be the cause of synovial cyst formation.
3
Our patient developed a synovial cyst after revision of a failed hamstring ACL reconstruction using a BPTB allograft. We found no reports of pretibial cyst formation after such surgery. No bone grafting was performed to occlude the primary tibial tunnel at the time of revision surgery. It is possible that bone grafting during revision surgery to occlude the primary tibial tunnel could have prevented synovial cyst formation in our patient. We conclude that pretibial cyst formation is a rare complication after arthroscopic ACL reconstruction. Patients undergoing revision ACL reconstruction may be more likely to develop such a synovial cyst. Bone grafting the original tibial tunnel may help prevent this rare complication, if the revision tunnel is created in a different location. Careful debridement and bone grafting should lead to the resolution of the ganglion cyst. REFERENCES 1. Buss DD, Warren RF, Wickiewicz TL, et al. Arthroscopically assisted reconstruction of the anterior cruciate ligament with the use of autogenous patellar ligament grafts. J Bone Joint Surg Am 1993;75:1346-1355. 2. Harner CH, Marks PH, Fu FM, et al. Anterior cruciate ligament reconstruction: Endoscopic versus two-incision technique. Arthroscopy 1994;5:502-512. 3. Kartus J, Magnusson L, Stener S, et al. Complications following arthroscopic anterior cruciate ligament reconstruction: A 2-5 year follow-up of 604 patients with special emphasis on anterior knee pain. Knee Surg Sports Traumatol Arthrosc 1999;7:2-8. 4. Tierney GS, Wright RW, Smith JP. Anterior cruciate ligament reconstruction as an outpatient procedure. Am J Sports Med 1995;23:755-756. 5. Clancy WG, Ray JM, Zoltan DJ. Acute tears of the anterior cruciate ligament. J Bone Joint Surg Am 1988;70:1483-1488. 6. Deie M, Sumen Y, Ochi M, et al. Pretibial cyst formation after anterior cruciate ligament reconstruction using auto hamstring grafts: Two case reports in a prospective study of 89 cases. Magn Reson Imaging 2000;18:973-977. 7. Simonian PT, Wickiewicz TL, O’Brien SJ, et al. Pretibial cyst formation after anterior cruciate ligament surgery with soft tissue autografts. Arthroscopy 1998;14:215-220. 8. Victoroff BN, Paulos L, Beck C, Goodfellow DB. Subcutaneous pretibial cyst formation associated with anterior cruciate ligament allografts: A report of four cases and literature review. Arthroscopy 1995;11:486-494. 9. Feldmann DD, Fanelli GC. Development of a synovial cyst following anterior cruciate ligament reconstruction. Arthroscopy 2001;17:200-202. 10. Martinek V, Friederich NF. Tibial and pretibial cyst formation after anterior cruciate ligament reconstruction with bioabsorbable interference screw fixation. Arthroscopy 1999;15:317-320. 11. Brettler D, Soudry M. Tibial bone plug resorption with extraarticular cyst: A rare complication of anterior cruciate ligament reconstruction. Arthroscopy 1995;11:478-481. 12. Benedetto KP, Fellinger M, Lim TE, et al. A new bioabsorbable interference screw: Preliminary results of a prospective, multicenter, randomized clinical trial. Arthroscopy 2000;16: 41-48.
Pretibial Cyst Formation After Arthroscopic Anterior Cruciate Ligament Reconstruction Omer A. Ilahi, M.D., Shiraz A. Younas, M.D., and Irvin K. Sahni, M.D.
Abstract: Pretibial cyst formation is a rare occurrence after anterior cruciate ligament (ACL) reconstruction. We report this complication after ACL reconstruction using a hamstring autograft. Bone grafting of the original tibial tunnels during revision surgeries after failed ACL reconstruction could prevent this rare complication. Key Words: ACL reconstruction—Cyst—Ganglion—Hamstring.
A
rthroscopic reconstruction of the anterior cruciate ligament (ACL) using autograft or allograft is commonly performed, and results, including stability and functioning, have been satisfactory.1-5 Complications are few and include stiffness, quadriceps weakness, bleeding, swelling, and infection.3 Synovial cyst formation is a rare complication after ACL reconstruction.6-10 However, researchers have suggested that revision surgeries pose a greater risk of synovial cyst formation due to the presence of multiple tunnels.7 Although studies have reported synovial ganglion formation after primary ACL reconstruction using hamstring grafts, there is a dearth of reports of this complication after a revision ACL reconstruction. The authors report formation of a pretibial synovial cyst after revision ACL reconstruction. CASE REPORT A 27-year-old woman presented with complaints of pain in the inferomedial aspect of her left knee. She
From the Department of Orthopedics, Baylor College of Medicine, Houston, Texas, U.S.A. Address correspondence and reprint requests to Omer A. Ilahi, M.D., 6560 Fannin, Suite 1016, Houston, TX. 77030, U.S.A. Email: [email protected] © 2003 by the Arthroscopy Association of North America 1526-3231/03/1902-3181$30.00/0 doi:10.1053/jars.2003.50045
had injured her ACL while playing soccer and underwent ACL reconstruction using a hamstring autograft in 1991. She did well after that surgery, regaining full range of motion and returning to sports. However, in 1998, she tore the reconstructed ligament while playing racquetball. She underwent an ACL revision surgery using a bone–patellar tendon– bone (BPTB) allograft with use of a 2-incision technique. At the time of revision, a separate tibial tunnel was drilled. No bone grafting of the tibial tunnel from the first reconstruction was performed. Afterward, the patient again regained full motion and returned to sports. One year after the revision procedure, the patient presented with new onset of a painful limp. There was tenderness localized to the area of insertion of an interference screw in the left tibia. The patient reported activity-related swelling in this area. Left knee range of motion was equal to the right knee: from 10° of hyperextension to 135° of flexion. The knee was stable, with negative Lachman’s and pivot shift tests. Radiographs revealed that tibial and femoral metallic interference screws were in place, with the tunnels in good position. The pain and swelling were thought to be because of irritation from the prominent tibial interference screw resulting in intermittent bursitis. Because of continuing symptoms, the patient elected to undergo elective removal of hardware. At surgery, examination under anesthesia revealed a stable knee with no effusion. KT-1000 measurements showed manual maximum excursion of 13 mm on the
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 2 (February), 2003: E5
1
2
O. A. ILAHI ET AL.
left and 11.5 mm on the right knee, indicating competent graft function. Arthroscopic examination revealed a viable ACL graft with good tension. Some fraying of the anterior fibers was noted. The femoral trochlear notch had some regrowth of cartilage along the margins. In addition, areas of chondromalacia on the medial femoral condyle and the patella were seen. The frayed fibers were debrided using a motorized shaver. After removing the arthroscopic instruments, a cystic palpable mass was identified over the proximal aspect of the tibia in the area of previous incisions. A 3-cm incision was created over the area of localized swelling medial to the tibial tubercle. A cystic mass was encountered and carefully dissected away from the surrounding subcutaneous tissue (Fig 1). The mass was incised, and a clear gelatinous material was seen, indicating the mass to be a ganglion cyst. The cyst was excised intact. There was a stalk that tracked into a hole in the proximal tibia, which could be traced back to the knee joint just anterior to the tibial insertion of the ACL graft. This tunnel was carefully curetted to remove any soft tissue and gelatinous material. The interference screw itself was seen to be just distal to this tunnel and was removed, leaving a small tunnel. Both tunnels were probed with radio-opaque instruments to determine the tunnel depths. The proximal tunnel was large enough to allow a hemostat to pass directly into the knee joint, just anterior to the ACL graft. The more distal tunnel was a blind tunnel created by removal of the interference screw (Fig 2). Both tunnels were packed with lyophilized bone graft. Arthroscopy was performed to insure that no bone graft extruded into the joint.
FIGURE 2. Intraoperative lateral radiograph of the knee with instruments in the proximal and distal tunnels. The curette is inserted into the tunnel created during the initial ACL reconstruction. The hemostat is inserted into the tunnel created by removing the interference screw used for tibial fixation of the revision procedure.
The cyst and gelatinous material were sent for pathologic examination, which revealed fibrous tissue containing multiple cystic spaces lacking an epithelial lining and containing myxoid material consistent with a ganglion cyst. No acute or chronic inflammation was found on microscopic examination. On last follow-up, 2 months after surgery, the patient was doing well and had not developed a recurrence of the synovial cyst. She was walking without a limp and had regained full range of motion with no knee instability. DISCUSSION
FIGURE 1. cyst.
Intraoperative photograph of the pretibial synovial
Various investigations have evaluated the occurrence of complications after arthroscopic ACL reconstruction. One study conducted in Japan followed 89 patients using magnetic resonance imaging (MRI) to
PRETIBIAL CYST FORMATION detect pretibial cysts as complications after ACL reconstruction using semitendinosus-gracilis grafts. They found cysts in 2 patients, a rate of 2.2%. The authors concluded that cyst formation occurred as a result of tendon necrosis during the process of incorporation into the osseous tunnel at 6 to 12 months.6 Some researchers have suggested that using a bone plug in ACL reconstruction decreases the risk of postoperative synovial cyst formation. Reports of cyst formation after hamstring reconstruction seem to be more common than after BPTB reconstructions. Simonian et al.7 reported 3 cases of pretibial ganglion formation after ACL reconstruction using hamstring grafts and 1 after ACL reconstruction using the iliotibial tract. Those authors reported no cases of cyst formation in those patients in whom a graft with a bone plug was used. Debridement and bone grafting successfully resolved the problem in the 3 patients symptomatic enough to warrant surgical treatment.7 Brettler and Soudry11 reported a case of pretibial cyst formation after use of a BPTB autograft in a 41-year-old man. This complication developed about 18 months after ACL reconstruction and was associated with enlargement of the tibial tunnel with loosening of the interference screw. Those authors concluded that the cyst developed as a result of excessive irritation due to femoral notch impingement that allowed synovial fluid to dissect down the graft under pressure, leading to resorption and failure of the bone plug. Victoroff et al.8 reported 3 cases of pretibial cyst formation after use of a patellar tendon allograft without a bone plug. They also reported 1 case of pretibial cyst formation in a patient in whom a hamstring graft was used without a bone plug. The authors recommended the use of bone plugs to avoid this complication. Martinek and Friederich10 reported a case in which a 32-year-old man developed an osteolytic cyst in the tibial tunnel with resorption of the bone plug after use of a poly-D,L-lactide interference screw. Those authors concluded that the cyst formation was a complication related to use of the poly-D,L-lactide interference screw. A later clinical trial on a new polygluconate interference screw reported 1 case of subcutaneous cyst formation in 124 patients who underwent ACL reconstruction with a BPTB autograft and this bioabsorbable interference screw.12 Also, Feldmann and Fanelli9 reported 1 case of a synovial cyst originating from the femoral tunnel. Nonabsorbable suture left in the graft was thought to be the cause of synovial cyst formation.
3
Our patient developed a synovial cyst after revision of a failed hamstring ACL reconstruction using a BPTB allograft. We found no reports of pretibial cyst formation after such surgery. No bone grafting was performed to occlude the primary tibial tunnel at the time of revision surgery. It is possible that bone grafting during revision surgery to occlude the primary tibial tunnel could have prevented synovial cyst formation in our patient. We conclude that pretibial cyst formation is a rare complication after arthroscopic ACL reconstruction. Patients undergoing revision ACL reconstruction may be more likely to develop such a synovial cyst. Bone grafting the original tibial tunnel may help prevent this rare complication, if the revision tunnel is created in a different location. Careful debridement and bone grafting should lead to the resolution of the ganglion cyst. REFERENCES 1. Buss DD, Warren RF, Wickiewicz TL, et al. Arthroscopically assisted reconstruction of the anterior cruciate ligament with the use of autogenous patellar ligament grafts. J Bone Joint Surg Am 1993;75:1346-1355. 2. Harner CH, Marks PH, Fu FM, et al. Anterior cruciate ligament reconstruction: Endoscopic versus two-incision technique. Arthroscopy 1994;5:502-512. 3. Kartus J, Magnusson L, Stener S, et al. Complications following arthroscopic anterior cruciate ligament reconstruction: A 2-5 year follow-up of 604 patients with special emphasis on anterior knee pain. Knee Surg Sports Traumatol Arthrosc 1999;7:2-8. 4. Tierney GS, Wright RW, Smith JP. Anterior cruciate ligament reconstruction as an outpatient procedure. Am J Sports Med 1995;23:755-756. 5. Clancy WG, Ray JM, Zoltan DJ. Acute tears of the anterior cruciate ligament. J Bone Joint Surg Am 1988;70:1483-1488. 6. Deie M, Sumen Y, Ochi M, et al. Pretibial cyst formation after anterior cruciate ligament reconstruction using auto hamstring grafts: Two case reports in a prospective study of 89 cases. Magn Reson Imaging 2000;18:973-977. 7. Simonian PT, Wickiewicz TL, O’Brien SJ, et al. Pretibial cyst formation after anterior cruciate ligament surgery with soft tissue autografts. Arthroscopy 1998;14:215-220. 8. Victoroff BN, Paulos L, Beck C, Goodfellow DB. Subcutaneous pretibial cyst formation associated with anterior cruciate ligament allografts: A report of four cases and literature review. Arthroscopy 1995;11:486-494. 9. Feldmann DD, Fanelli GC. Development of a synovial cyst following anterior cruciate ligament reconstruction. Arthroscopy 2001;17:200-202. 10. Martinek V, Friederich NF. Tibial and pretibial cyst formation after anterior cruciate ligament reconstruction with bioabsorbable interference screw fixation. Arthroscopy 1999;15:317-320. 11. Brettler D, Soudry M. Tibial bone plug resorption with extraarticular cyst: A rare complication of anterior cruciate ligament reconstruction. Arthroscopy 1995;11:478-481. 12. Benedetto KP, Fellinger M, Lim TE, et al. A new bioabsorbable interference screw: Preliminary results of a prospective, multicenter, randomized clinical trial. Arthroscopy 2000;16: 41-48.