Pretibial swelling following ACL-reconstruction

A 42-year-old male recreational football player presented with a two-month history of pretibial swelling. He reports having had an ACL-reconstruction (ACLR) 16 years previously. The swelling is variably present, developed after increasing his physical activity and was not associated with any other symptoms. In particular there was no pain, instability or locking. On examination, there is localised pretibial swelling but an otherwise normal knee examination.

An ultrasound scan shows a pretibial fluid-collection (hypo-echogenic), interruption of the tibial cortex and a possible continuous connection with the tibial tunnel. A subsequent MRI better demonstrates the pretibial tunnel, the interruption of the tibial cortex and the pretibial swelling (high signal). There is a continuous connection between the tibial tunnel and the swelling.

The player was managed with reassurance and with local treatments (including compression and ice) and a reduction in activity. He was then able to return to normal activities and was relatively unconcerned about this swelling.

During ACL-surgery, a tibial tunnel is drilled to pull the graft through the tunnel and fixate it. Bone tunnel widening is a frequently found phenomenon after ACLR. The causes of the widening are not fully understood yet. A knee effusion may transfer through the tunnel and cause pretibial swelling.

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