S P E C I A L F O C U S

Sports Medicine
Cyclops lesions after ACL reconstruction using either
bone-tendon-bone autograft or hamstring autograft:
A retrospective cohort study
Zachary K. Pharr, MDa, Anthony A. Mascioli, MDa, Andrew B. Dickerson, BSb, Thomas W. Throckmorton, MDa
and Frederick M. Azar, MDa

a
University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, Memphis, TN
b
University of Tennessee Health Science Center, College of Medicine, Memphis, TN

potential complication that has not been previously compared

ABSTRACT between these two graft options. We found no statistically significant
Background: difference in the frequency of cyclops lesions between the two groups,
ACL reconstruction is commonly performed with either bone- minimizing any concern for an increased risk of a cyclops lesion when
patellar tendon-bone (BPTB) autograft or hamstring autograft, each choosing BPTB autograft or hamstring autograft. Surgeons should be
of which has inherent advantages and disadvantages; to our cognizant that the relative risk of a cyclops lesion is four times higher in
knowledge, no study has compared the frequency of cyclops female patients than in male patients with either graft.
lesions between the two autografts. By focusing on cyclops lesions,
a source of knee extension loss after ACL reconstruction, we aimed Level of Evidence:
to expand the comparison between these two autograft options. Level III.

Methods: Key Words

A single-center, retrospective chart review identified 1,902 patients anterior cruciate ligament reconstruction, bone-tendon-bone,
between the ages of 8 and 66 yr who had ACL reconstruction hamstring autograft, cyclops lesion
between January 1, 2000, and October 31, 2015. Of these, 1534
received a BPTB autograft and 368 a hamstring autograft. Cyclops
lesions were confirmed by a second arthroscopy in patients treated
for loss of full knee extension, and the occurrences with BPTB and
hamstring autograft were compared. INTRODUCTION
Results:

T
he incidence of anterior cruciate ligament (ACL) injuries
Cyclops lesions occurred in 14 (0.91%) of 1,534 reconstructions
is currently estimated at over 200,000 annually, with
with BPTB autografts and five (1.35%) of 368 with hamstring
orthopaedic surgeons performing around 100,000 ACL
autografts (P = 0.39); this difference was not statistically significant.
Cyclops lesions occurred in five (0.44%) of 1125 males and 14 reconstructions per year.1,2 In the United States, ACL injuries
(1.44%) of 777 females (P = 0.004). This was statistically significant, result in approximately $18,000 to $28,000 in surgical and
illustrating a more frequent occurrence of cyclops lesions in female rehabilitative costs per patient.3 Mather et al.4 determined that
patients than in male patients with a relative risk of 4 (CI 1.4-11). the mean lifetime cost to society for a typical patient under-
going ACL reconstruction was $38,121, compared with
Conclusions: $88,538 for rehabilitation. ACL injury is most prevalent (one
Bone-patellar tendon-bone and hamstring autografts both are viable in 1,750 persons) in patients 15 to 45 yr of age, generally
options for ACL reconstruction. The occurrence of cyclops lesions is a because of their more active lifestyle as well as more frequent
participation in sports.1,5 Given the aforementioned reasons, it
is important to know the best surgical options.
Financial Disclosure: Dr. Throckmorton discloses financial Historically, the two autografts used most commonly for
relationships outside this work with IP, Biomet Zimmer, and ACL reconstruction are bone-patellar tendon-bone (BPTB) and
Elsevier, and Dr. Azar with 98point6, Myoscience, Pfizer, hamstring, each with inherent advantages and disadvantages.
Wolters Kluwer, and Zimmer. The other authors have no
Postoperative graft failure and knee laxity are less frequent with
disclosures. The authors report no conflicts of interest.
Correspondence to Thomas W. Throckmorton, MD, 1211 Union Avenue,
BPTB, but anterior knee pain is more common.6–8 Advantages
Suite 510, Memphis, TN 38104 of hamstring autografts include faster recovery of motion and
Tel: +901-759-3270; fax: +901-759-3278; fewer problems with knee pain than with BPTB.9–13
e-mail: [email protected]. Knee extension loss can occur with either graft, most
1941-7551 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. commonly because of graft impingement after tunnel

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malpositioning. Another common cause of knee extension Memphis, Tennessee (approval no. 16-04425-XP). Informed
loss after ACL reconstruction is localized anterior arthrofib- consent was waived.
rosis, also known as a “cyclops lesion.”14,15
Cyclops lesions are fibroproliferative scars reported to occur Patient Population
in 1% to 25% of patients after ACL reconstruction16,17 and A single-center, retrospective review identified 2,046 patients
cause pain and crepitance and can block full knee extension. between the ages of 8 and 66 yr treated with ACL reconstruction
Histologically, the lesion consists of central granulation tissue between January 1, 2000 and October 31, 2015. Patients treated
surrounded by dense fibrous tissue, evolving from stages of with an allograft or autograft other than BPTB or hamstring
fibrosis to fibrocartilaginous soft tissue.17 The pathogenesis of autograft were excluded from the study, leaving 1534 patients
the cyclops lesion is multifactorial; drilling of the tibial tunnel with BPTB autografts and 368 with hamstring autografts for a
or impingement of the exposed fibers of the ACL on the total of 1902 ACL reconstructions for review (Figure 1). Due to the
intercondylar notch may contribute to its development.15,17–19 high number study, sample size was not calculated.
It also has been suggested that repetitive microtrauma damages
and exposes collagen within grafts, leading to neovasculariza- ACL Reconstruction and Follow-up
tion and hyperplasia that form these lesions.20,21 MRI scanning
ACL reconstructions were performed by 10 different orthopaedic
often reveals the lesion after a patient presents with lack of full
surgeons (three sports medicine fellowship trained and seven
knee extension. Clinically, patients typically present within 4
general) using their preferred technique regarding tibial and
to 6 mo after ACL reconstruction,14,16 but delayed presentation
femoral tunnel placement and graft fixation. ACL reconstruc-
up to 4 yr has been reported.22 Treatment consists of arthro-
tions were performed on an elective basis once the patient had
scopic excision and notchplasty if needed for impingement.23
obtained near full knee range of motion. After ACL reconstruc-
The purpose of this study was to compare the incidence of
tion, each patient underwent physical therapy with a standard-
cyclops lesions with BPTB and hamstring ACL reconstructions.
ized knee program and serial follow-up visits.
To our knowledge, this has not been extensively studied, and
comparative data on cyclops lesions between these two surgical
Identification of Cyclops Lesions and
options may assist in the choice of graft. In addition, we
Comparisons with Graft Type
explored the possibility of a higher incidence of cyclops lesions
based on gender, comparing males to females as a secondary To determine undoubtedly that a cyclops lesion had occurred,
outcome. It was our hypothesis that there would be little or no cyclops lesions were included only if they were identified on a
difference in the incidence of cyclops lesions according to the second arthroscopic procedure. Thus, the focus of the electronic
graft used or the gender of the patients. medical review was on any patient who underwent an additional
surgery after primary ACL reconstruction. If a patient was found
to have undergone a secondary arthroscopic procedure, the
MATERIALS AND METHODS operative report and clinical photos were reviewed to determine if
a cyclops lesion was identified intraoperatively by direct arthro-
Ethical Review and Study Design scopic visualization (Figure 2). These patients had elected to
This retrospective cohort study was approved by the Institu- undergo a secondary arthroscopic debridement because of failure
tional Review Board of the the University of Tennessee, to achieve satisfactory knee range of motion (+/− pain), lacking

FIGURE 1. Study flow chart.

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FIGURE 2. A 17-year-old female with knee extension loss after anterior cruciate ligament reconstruction with a bone-patellar tendon-bone autograft.
A, Cyclops lesion. B, After debridement of cyclops lesion.

symmetrical extension compared to the opposite knee after their with BPTB autografts and five (1.35%) of 368 with hamstring
primary ACL reconstruction. MRI was not routinely used prior to autografts (P = 0.39). When the data were stratified by gender,
the second procedure, and patients treated only with closed 11 (1.87%) of 589 female patients with BPTB autografts and
manipulation certainly did not have a cyclops lesion identified by three (1.59%) of 188 with hamstring autografts had cyclops
direct arthroscopic visualization. lesions (P = 0.549) (Table 1). Three (0.31%) of 945 male patients
The incidence of cyclops lesions identified in this manner with BPTB autografts and two (1.11%) of 180 with hamstring
following ACL reconstructions with BPTB autograft and autografts had cyclops lesions (P = 0.183). Thus, there was no
hamstring autografts were subsequently compared. Because statistically significant difference in the incidence of cyclops
the hamstring autograft group had a higher percentage of lesions between the two graft options (P = 0.39). When gender
female patients than the BPTB autograft group (P = 0.0001), was compared, cyclops lesions occurred in five (0.44%) of 1125
gender was stratified prior to statistical analysis. In addition, males and 14 (1.44%) of 777 females (P = 0.004); the relative
the frequency of cyclops lesions in male and female patients risk in females was 4 (CI 1.4-11).
undergoing ACL reconstruction was compared.

DISCUSSION
Statistical Analysis
For statistical analysis, the Fisher’s exact test for categorical To our knowledge, no study has compared the frequency of
data was used instead of Pearson’s chi square test to account cyclops lesions with BPTB autograft and hamstring autograft
for the small sample size of cyclops lesion incidence. A P ACL reconstructions. Cha et al.24 studied the prevalence of
value was set at <0.05 for statistical significance. cyclops lesions after ACL reconstruction, comparing single-
bundle and remnant-bundle preservation techniques; however,
all reconstructions were done with hamstring grafts. They found
RESULTS similar prevalences of cyclops lesions in the two groups. Marzo
This cohort of 1902 ACL reconstructions consisted of 1125 et al.25 reported 21 patients with BPTB or hamstring autograft
males and 777 females with a mean age of 27 yr (range, 8 to 66 ACL reconstructions who had loss of extension because of an
yr) (Table 1). The overall incidence of cyclops lesions was 1%. ACL nodule. They made no real comparison between the two
Cyclops lesions were identified in 14 (0.91%) of 1534 patients surgical options and postulated that cyclops lesion formation
occurred because of placement of the graft too far anterior on
the tibia. Dandy et al.23 compared loss of knee extension with
TABLE 1. Patient demographics and frequency of BPTB autografts and Leeds-Keio ligament prosthesis and found
cyclops lesions cyclops lesions in 37 (24%) of 154 reconstructions with BPTB
autografts and in one (2.5%) of 40 with Leeds-Keio ligaments
BPTB Hamstring prostheses. They cited Cannon and Vitorri26 as having similar
autograft autograft
extension loss problems with hamstring autografts and postu-
Number of patients 1534 368 lated that the problem was based on biologic grafts.
Age 27.8 yr 25.7 yr
Male 945 (62%) 180 (49%)
When comparing BPTB and hamstring ACL reconstruc-
Female 589 188 tions, we found similar incidences of cyclops lesions at
Cyclops lesion around 1% overall, regardless of the graft option used. This is
Frequency 14 (0.91%) 5 (1.35%) P = 0.39 on the low end of rates reported in the literature.15,16,19 This
Gender 11 female 3 female P = 0.004 study indicates that the biology of BTPB autograft versus
(1.86%) (1.6%)
3 male 2 male hamstring autograft does not appear to be more prone to the
(0.3%) (1.1%) development of a cyclops lesion.
This study also points out that surgeons should be
BPTB, bone-patellar tendon-bone.
cognizant of the four times higher frequency of cyclops

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lesions in female patients after ACL reconstruction. Fujii REFERENCES

et al.27 had similar findings with a study involving 55
patients. They evaluated notch size with MRI and postulated 1. American Academy of Orthopaedic Surgeons. Anterior cruciate
that a smaller intercondylar notch may be a potential risk ligament injury: surgical considerations. 2008. Available at:
factor for cyclops lesion formation. Csintalan et al.14 found http://orthoinfo.aaos.org/topic.cfm?topic=A00297#A00297_R4_
female gender to be a risk factor for subsequent surgery for anchor. Accessed October 27, 2017.
2. Buller LT, Best MJ, Baraga MG, et al. Trends in anterior cruciate
arthrofibrosis in their study of 14,522 primary ACL recon- ligament reconstruction in the United States. Orthop J Sports Med.
structions; graft type was not found to be a risk factor. In a 2015; 3:2325967114563664.
study of 933 ACL reconstructions in adolescent patients, 3. Hewett TE, Lindenfeld TN, Riccobene JV, et al. The effect of
Nwachukwu et al.28 found that female patients were almost neuromuscular training on the incidence of knee injury in
female athletes: a prospective study. Am J Sports Med. 1999;
three times more likely to develop arthrofibrosis than male 27:699–706.
patients, and Sanders et al.29 reported a 2.5 times higher 4. Mather RC III, Koenig L, Kocher MS, et al. Societal and economic
frequency of arthrofibrosis in female patients. However, in impact of anterior cruciate ligament tears. J Bone Joint Surg Am.
their meta-analysis, Tan et al.30 did not identify a statistically 2013; 95:1751–1759.
significant difference in the frequency of cyclops lesions 5. Griffin LY. Noncontact anterior cruciate ligament injuries: risk
factors and prevention strategies. J Amer Acad Orthop Surg. 2000;
between male and female patients, and Facchetti et al.16 also 8:141–150.
found no significant differences between patients with or 6. Gifstad T, Foss OA, Engebretsen L, et al. Lower risk of revision
without cyclops lesions regarding age, gender, or type of graft with patellar tendon autografts compared with hamstring
in 113 patients. Our findings align with those of Csintalan autografts: a registry study based on 45,998 primary ACL
reconstructions in Scandinavia. Am J Sports Med. 2014;
et al.,14 Fujii et al.,27 Nwachukwu et al.,28 and Sanders et al.29 42:2319–2328.
in that cyclops lesions were four times as frequent in female 7. Persson A, Fjeldsgaard K, Gjertsen JE, et al. Increased risk of
patients as in male patients. revision with hamstring tendon grafts compared with patellar
This study has its limitations, predominantly because of tendon grafts after anterior cruciate ligament reconstruction:
a study of 12,643 patients from the Norwegian Cruciate Ligament
its retrospective design. There were multiple surgeons
Registry, 2004-2012. Am J Sports Med. 2014; 42:285–291.
involved with varying techniques of tunnel placement 8. Rahr-Wagner L, Thillemann TM, Pedersen AB, et al. Comparison
(transtibial, anteromedial, retrograde femoral, all-inside), of hamstring tendon and patellar tendon grafts in anterior
ACL remnant management, notchplasty, and graft fixation. cruciate ligament reconstruction in a nationwide population-
This would certainly lead to variations in tunnel position- based cohort study: results from the Danish registry of
knee ligament reconstruction. Am J Sports Med. 2014; 42:
ing throughout 1902 ACL reconstructions. However, it 278–284.
does make this study more applicable to the general 9. Freedman KB, D’Amato MJ, Nedeff DD, et al. Arthroscopic
community of orthopaedic surgeons, and the purpose of anterior cruciate ligament reconstruction: a metaanalysis com-
this study was not to compare extension loss secondary to paring patellar tendon and hamstring tendon autografts. Am J
Sports Med. 2003; 31:2–11.
tunnel malposition but to determine if the incidence of
10. Pinczewski LA, Deehan DJ, Salmon LJ, et al. A five-year
cyclops lesions was more common with a certain autograft comparison of patellar tendon versus four-strand hamstring
(BPTB vs. hamstring), indicating a possible biologic corre- tendon autograft for arthroscopic reconstruction of the anterior
lation. We thought the best way to truly confirm a cyclops cruciate ligament. Am J Sports Med. 2002; 30:523–536.
lesion was when it was seen during direct arthroscopic 11. Sachs R, Daniel D, Stone M, et al. Patellofemoral problems after
anterior cruciate ligament reconstruction. Am J Sports Med. 1989;
visualization. 17:760–765.
Furthermore, the comparison groups had significant 12. Shaieb MD, Kan DM, Chang SK, et al. A prospective randomized
differences in gender: female patients comprised 39% of comparison of patellar tendon versus semitendinosus and
the BPTB autograft group and 51% of the hamstring gracilis tendon autografts for anterior cruciate ligament recon-
autograft group (P = < 0.01); however, this discrepancy was struction. Am J Sports Med. 2002; 30:214–220.
13. Xie X, Liu X, Chen Z, et al. A meta-analysis of bone-patellar
accounted for by comparing the two graft options with the tendon-bone autograft versus four-strand hamstring tendon
gender stratified (i.e, comparing female patients with BPTB autograft for anterior cruciate ligament reconstruction. Knee.
grafts to female patients with hamstring grafts). After gender 2015; 22:100–110.
stratification, the overall number of cyclops lesions being 14. Csintalan RP, Inacio MC, Funahashi TT, et al. Risk factors of
subsequent operations after primary anterior cruciate ligament
compared was low, which makes the statistical analysis less reconstruction. Am J Sports Med. 2014; 42:619–625.
powerful. A higher sample size with more cyclops lesions 15. Recht MP, Piraino DW, Cohen MA, et al. Localized anterior
would help confirm these conclusions. arthrofibrosis (cyclops lesion) after reconstruction of the anterior
cruciate ligament: MR imaging findings. AJR Am J Roentgenol.
1995; 165:383–385.
16. Facchetti L, Schwaiger BJ, Gersing AS, et al. Cyclops lesions
CONCLUSIONS detected by MRI are frequent findings after ACL surgical
reocnstruction but do not impact clinical outcome over 2 years.
In summary, cyclops lesions are a low risk in ACL Eur Radiol. 2017; 27:3499–3508.
reconstructions and are seen equally with BPTB and ham- 17. Sheldon PJ, Forrester DM, Learch TJ. Imaging of intra-articular
string autografts. Surgeons should be aware of the increased masses. Radiographics. 2005; 25:105–119.
incidence of cyclops lesions in female patients after this 18. Bradley DM, Bergman AG, Dillingham MF. MR imaging of
cyclops lesions. AJR Am J Roentgenol. 2000; 174:719–726.
operation. Further studies are necessary to help identify 19. Recht MP, Piraino DW, Applegate G, et al. Complications after
causes for and ways to prevent the increased frequency of anterior cruciate ligament reconstruction: Radiographic and MR
cyclops lesions in our female patients. findings. AJR Am J Roentgenol. 1996; 167:705–710.

Copyright r 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Current Orthopaedic Practice www.c-orthopaedicpractice.com | 5

20. Delcogliano A, Franzese S, Branca A, et al. Light and scan electron 25. Marzo JM, Bowen MK, Warren RF, et al. Intraarticular fibrous
microscopic analysis of cyclops syndrome: etiopathogenic nodule as a cause of loss of extension following anterior cruciate
hypothesis and technical solutions. Knee Surg Sports Traumatol ligament reconstruction. Arthroscopy. 1992; 8:10–18.
Arthrosc. 1996; 4:194–199. 26. Cannon WD Jr, Vittori JM. The role of arthroscopic debridement
21. Delince P, Krallis P, Descamps PY, et al. Different aspects of the after anterior cruciate ligament reconstruction. Arthroscopy.
cyclops lesion following anterior cruciate ligament reconstruc- 1991; 7:344–349.
tion: a multifactorial etiopathogenesis. Arthroscopy. 1998; 14: 27. Fujii M, Furumatsu T, Miyazawa S, et al. Intercondylar notch size
869–876. influences cyclops formation after anterior cruciate ligament
22. Balcarek P, Sawallich T, Losch A, et al. Delayed cyclops reconstruction. Knee Surg Sports Traumatol Arthrosc. 2015; 23:
syndrome: symptomatic extension block four years after anterior 1092–1099.
cruciate ligament reconstruction. Acta Orthop Belg. 2008; 74: 28. Nwachukwu BU, McFeely ED, Nasreddine A, et al. Arthrofibrosis
261–265. after anterior cruciate ligament reconstruction in children and
23. Dandy DJ, Edwards DJ. Problems in regaining full extension of adolescents. J Pediatr Orthop. 2011; 31:811–817.
the knee after anterior cruciate ligament reconstruction: does 29. Sanders TL, Kremers HM, Bryan AJ, et al. Procedural intervention
arthrofibrosis exist? Knee Surg Sports Traumatol Arthrosc. 1994; for arthrofibrosis after ACL reconstruction: trends over two
2:76–79. decades. Knee Surg Sports Traumatol Arthrosc. 2017; 25:532–537.
24. Cha J, Choi SH, Kwon JW, et al. Analysis of cyclops lesions after 30. Tan SH, Lau BP, Khin LW, et al. The importance of patient sex in
different anterior cruciate ligament reconstructions: a compar- the outcomes of anterior cruciate ligament reconstructions:
ison of the single-bundle and remnant bundle preservation a systematic review and meta-analysis. Am J Sports Med. 2016;
techniques. Skeletal Radiol. 2012; 41:997–1002. 44:242–254.

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