Remnant preservation and stump suturing in anterior cruciate ligament reconstruction reduce tibial tunnel widening without compromising tunnel placement: A computed tomography-based randomised controlled trial
In brief
Preserving ACL remnants cuts significant tibial tunnel widening from 25% to 11%
In a randomized trial of 179 patients, remnant preservation with tibial stump suturing reduced tunnel widening over one year: 11% had widening greater than 20%, compared with 25% after stump resection. Femoral widening and tunnel placement were similar between groups, but whether the smaller tibial changes improve graft incorporation or revision outcomes remains unknown.
- Journal
- Journal of experimental orthopaedics (Q1)
- Published
- 28 October 2026
- Study design
- Randomized controlled trial
- Evidence level
- Level 1, High (CEBM 1b)
- Authors
- Mahmoud El-Desouky, Ahmed Samir Elkalyoby, Amr Samir Rashwan, Amr Ibrahim Gaballah, Begad Hesham Abdelrazek
- PMID
- 42953369
- DOI
- 10.1002/jeo2.70962
Why clinicians should know about it
- Picked for Anatomy (top studies of the week, 1 November 2026): CT-based assessment of surgical tunnel placement and anatomy
Abstract
PURPOSE: Tunnel widening remains a concern following anterior cruciate ligament reconstruction because it may adversely affect graft incorporation and complicate revision surgery. Remnant preservation has been proposed as a strategy to reduce tunnel widening, but its effect on postoperative tunnel remodelling remains uncertain. This study aimed to determine whether remnant preservation with tibial stump suturing reduces tunnel widening without compromising tunnel placement accuracy. METHODS: In this prospective randomised controlled trial, 179 patients undergoing primary anterior cruciate ligament (ACL) reconstruction were randomised to remnant-preserving reconstruction with tibial stump suturing (n = 88) or conventional stump resection (n = 91). Standardised three-dimensional computed tomography was performed at 2 weeks and 1 year postoperatively. Tibial and femoral tunnel widening were calculated as the percentage change in tunnel diameter between scans, and tunnel placement accuracy was assessed using the computed tomography-based quadrant method. The incidence of clinically significant tunnel widening (>20%) was also compared. RESULTS: Baseline tunnel diameters were comparable between groups. At 1-year follow-up, remnant-preserving ACL reconstruction resulted in significantly less tibial tunnel widening than stump resection (14.58 ± 4.49% vs. 19.74 ± 4.36%, p < 0.001), with a lower incidence of clinically significant widening (>20%) (11.4% vs. 25.3%; relative risk, 0.45; p = 0.016). Femoral tunnel widening was similar between groups (18.23 ± 2.92% vs. 18.35 ± 2.59%, p = 0.766). No clinically relevant differences in tunnel placement were observed between groups. CONCLUSION: Remnant-preserving ACL reconstruction with tibial stump suturing selectively reduces tibial tunnel widening at 12 months without compromising anatomic tunnel placement accuracy. These findings support the use of remnant preservation when preservation of tibial tunnel integrity is a surgical consideration. LEVEL OF EVIDENCE: Level I. TRIAL REGISTRATION: ClinicalTrials.gov, NCT07236593; registration date: November 15, 2025 (retrospectively registered).
Abstract as published, via PubMed.
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