Pretibial cyst following anterior cruciate ligament reconstruction using hamstring autografts

Management of Chronic Transtibial Articulocutaneous Fistula After All-Inside ACL Reconstruction: A Case Report

CASE

A 29-year-old man presented 2 years after anterior cruciate ligament (ACL) reconstruction by autologous semitendinosus graft and suspensory fixation on both tibial and femoral sides for chronic drainage of clear fluid from an anteromedial wound at the site of the tibial tunnel with a visible sinus tract. Magnetic resonance imaging showed a transtibial articulocutaneous fistula. The patient was treated by tunnel debridement, impaction bone grafting, bioresorbable interference screw, and cement to fully seal the tunnel. The surgery was successful with good clinical outcomes for recurrence and knee stability.

CONCLUSION

Communicating transtibial articulocutaneous fistulas are rare complications after ACL reconstruction. Tunnel debridement and filling with graft material affected by an interference screw seem to be an effective method for dealing with such a clinical scenario.

A comprehensive scoping review of tibial cysts after anterior cruciate ligament reconstruction

Purpose

The purpose of this study was to perform a scoping review of published literature reporting on surgical management of tibial cysts which developed after ACLR.

Methods

A scoping review was conducted following the Arksey and O’Malley framework for scoping studies and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) guidelines. A search strategy using the terms [“Tibial Cyst” AND “ACL”], [“Pretibial Cyst” AND “ACL”] was applied to the PUBMED database.

Results

Thirty-seven studies published between 1990 and 2019 were a part of this scoping review. Non-absorbable implants for tibial graft fixation were used in 10 studies (comprising a total 21 patients), while bio-absorbable implants were used in 27 studies (comprising a total 115 patients). Incidence of tibial cyst was reported in 3 studies (434 primary ACLRs) from whom 3.9% (n = 17) developed tibial cyst. Tibial cyst development in relation to use of bio-absorbable screws for tibial ACL graft fixation was reported in 16 studies (42.1%). Use of bio-absorbable screws with another factor was found to be related to tibial cyst development in another 1 study (2.6%). Most common symptoms were presence of mass or swelling, pain, tenderness, drainage, instability and effusion.

Conclusion

This scoping review demonstrated that tibial cysts is more frequently related to bioabsorbable screws, however it can also occur due to other causes. Current literature on tibial cyst after ACLR is of low-quality evidence. Future research is required to better understand aetiology, risk factors for cyst formation and the best possible mode of management.

Level of evidence

IV

Supplementary Information

The online version contains supplementary material available at 10.1186/s40634-021-00356-9.

Painful pretibial pseudocyst at bioabsorbable interference screw aperture two years after anterior cruciate ligament reconstruction

We report the case of a patient with a painful subcutaneous nodule, measuring 13 mm × 17 mm, at the pretibial graft aperture site, which presented two years after a successful anterior cruciate ligament reconstruction with an autologous hamstring graft. A bioabsorbable poly-L-lactide interference screw was used for graft fixation at the tibial aperture. The patient underwent surgical excision of the lesion and curettage at the tunnel aperture. Grossly, extruded fragments of the screw and a thick pseudocapsule of surrounding tissue were excised. There was no communication between the tunnel aperture and the knee joint. The graft was also intact. Histological analysis revealed fragments of the bioabsorbable material in association with fibrous and granulomatous chronic inflammatory cells. This was consistent with a foreign body reaction. The patient subsequently recovered and resumed preinjury level of activity. To the best of our knowledge, this is the first report describing a nodular granulomatous type reaction to foreign bioabsorbable poly-L-lactide screw material subsequent to an anterior cruciate reconstruction surgery.

Early postoperative transtibial articular fistula formation after anterior cruciate ligament reconstruction: a review of three cases

INTRODUCTION

This is a retrospective case report of three cases with an early postoperative transtibial fistula after anterior cruciate ligament reconstruction (ACL).

MATERIALS AND METHODS

The patients had undergone ACL reconstruction and complained of fluid drainage through the not-healed wound or swelling localized on the anteromedial aspect of the ipsilateral proximal tibia during the early postoperative. Magnetic resonance imaging showed a multilocular fluid-filled cyst arising from the distal hole of the tibial bone tunnel. Open resection of the fistula and the cyst was performed in all cases and communication between the tibial tunnel and the joint space was confirmed. During revision surgery the distal hole of the tibial tunnel was covered with a fascio-periosteal flap.

RESULTS

All wounds healed without complications. There was no recurrence of drainage or cyst formation. At 2 years follow-up the knee function was normal and was not affected by the complication in any of the patients. Early postoperative transtibial fistulae after ACL reconstruction are rare complications that clinically present either as anterior tibial cysts or persistent wound drainage. Surgical treatment is required, and some delay in the rehabilitation routine is required, but the final outcome is not affected.

Pretibial cyst formation after anterior cruciate ligament reconstruction with a hamstring tendon autograft

We report a case of pretibial cyst formation, which is a rare complication, after anterior cruciate ligament (ACL) reconstruction. The patient had undergone ACL reconstruction at age 18 and complained of pain and swelling localized on the anteromedial aspect of the ipsilateral proximal tibia 2 years postoperatively. Magnetic resonance imaging showed a multilocular fluid-filled cyst arising from the outlet of the tibial bone tunnel. Open resection of the cyst was performed and communication between the tibial tunnel and the joint space was confirmed arthroscopically. The cavity of the tibial tunnel was packed with cancellous bone to seal off a water channel. The laboratory examination revealed slightly concentrated chondroitin sulfate in the cyst fluid compared with the articular fluid, despite histologic observation of no glycosaminoglycan synthesis in the cells of the cyst wall. These findings indicated that leakage of the articular fluid via the tibial tunnel might have caused the pretibial cyst after ACL reconstruction.