Independent Suture Tape Reinforcement of Small and Standard Diameter Grafts for Anterior Cruciate Ligament Reconstruction: A Biomechanical Full Construct Model

No Difference in Graft Signal Intensity on Magnetic Resonance Imaging or Clinical Outcome Between Anterior Cruciate Ligament Reconstruction With and Without Suture Augmentation

PURPOSE

To evaluate the safety of anterior cruciate ligament reconstruction (ACLR) with suture augmentation (SA) through clinical evaluations, monitoring of complications, and evaluation of early graft remodeling using magnetic resonance imaging (MRI).

METHODS

Data of participants who underwent anatomic double-bundle ACLR using hamstring tendon autografts, with a minimum 2-year follow-up, were retrospectively reviewed. Participants undergoing ACLR with SA were propensity-matched with those without SA. Postoperative clinical evaluations were recorded, including Lysholm Knee Scoring Scale, Tegner activity score, International Knee Documentation Committee (IKDC) evaluation scores, KT-1000 side-to-side difference for knee stability at a 2-year follow-up, and complications. The minimal clinically important difference (MCID) was calculated for IKDC scores. The anteromedial bundle graft was categorized into distal, middle, and proximal regions on the 6-month and 1-year postoperative MRIs. The signal-to-noise quotient (SNQ) of each region of interest was calculated to evaluate the graft signal intensity, which was compared between the 2 groups using Welch's t test.

RESULTS

Fifty-three participants were included in each group. No significant differences were observed between the non-SA and SA groups in the Lysholm scores (96.6 ± 6.2 and 95.3 ± 5.8, respectively; P = .25), Tegner activity scores (4.8 ± 1.4 and 5.0 ± 1.3, respectively; P = .49), IKDC scores (90.4 ± 10.8 and 87.1 ± 12.9, respectively; P = .15), percentage of patients meeting the MCID (94.3% and 83.0%, respectively; P = .12), or postoperative KT-1000 side-to-side difference (0.9 ± 1.2 and 0.7 ± 1.8 mm, respectively; P = .56). One (1.8%) and 2 (3.7%) cases of retears occurred in the non-SA and SA groups, respectively; no other complications occurred. The postoperative SNQ measurements revealed no significant differences in signal changes in all regions of the grafts between the 2 groups.

CONCLUSIONS

This study confirmed no difference in graft signal intensity on MRI or clinical outcome between ACLR with and without SA at the 2-year follow-up.

LEVEL OF EVIDENCE

Level III, retrospective, comparative study.

Editorial Commentary: Anterior Cruciate Ligament Reconstruction or Repair With Suture Augmentation Allows Early Rehabilitation: Collagen Co-braid Sutures May Improve Biological Integration

Suture augmentation in anterior cruciate ligament (ACL) reconstruction has the potential to combine improved long-term stability and high functional outcomes with accelerated rehabilitation, enhancing the biomechanical properties of the graft and reducing the risk of graft failure, particularly during the critical early phases of rehabilitation. Suture augmentation, applied to either ACL reconstruction (ACLR) or primary repair, introduces a "safety belt" synergistically sharing loads acting on the graft or repair. Several biomechanical studies using different autologous grafts for ACLR, as well as studies on ACL repair, have shown that suture augmentation enhances strength and prevents elongation of the graft or ligament. Suture augmentation can protect the graft-brace integrity under loads of 350 N, and reduces cyclic displacement by up to 31% compared with conventional ACLR using bone-patellar tendon-bone allograft. Perhaps, as above, the greatest advantage of suture augmentation is allowing early rehabilitation. Assuming successful ligamentization of the graft, the graft itself should stabilize the knee joint, thereby diminishing the long-term benefit of suture augmentation. In practice, we use suture augmentation to support immediate postoperative mobilization and weight bearing, enabling safe and early rehabilitation while minimizing the risk of failure. Regarding the oft-mentioned risk of overconstraint, this is not supported by biomechanical studies or clinical experience. The recent introduction of collagen co-braid sutures for suture augmentation offers 2 distinct advantages: first, potentially improved biocompatibility, and second, gradual biological integration allowing suture degradation over time.

Suture tape augmentation in the management of anterior cruciate ligament ruptures: a systematic review and meta-analysis

BACKGROUND

The employment of suture tape augmentation (SA) in surgical interventions for anterior cruciate ligament (ACL) ruptures is a subject of ongoing debate. This meta-analysis synthesizes prior research to assess the effectiveness of additional SA in treating ACL tears.

METHODS

A total of four databases including PubMed, Embase, Cochrane Library, and Web of Science were searched up to September 2024. Literature screening, quality evaluation, and data extraction were performed according to inclusion and exclusion criteria. Key data extracted include: Lysholm Knee Scoring Scale, International Knee Documentation Committee Score (IKDC), self-assessment numerical evaluation (SANE), Tegner Activity Score, Knee Injury and Osteoarthritis Outcome Score (KOOS), Veterans RAND 12-Item Health Survey (VR-12), Marx Activity Scale, visual analog scale (VAS), KT-1000 anteroposterior knee laxity, and return to sports rate. Meta-analysis of outcome indicators was performed using Revman 5.4 software.

RESULTS

A total of 17 articles were included in this meta-analysis. Pre-post operation effect analysis showed that additional SA was correlated with improved IKDC, Marx Activity Scale, KOOS, VR-12 physical, and VAS for pain. In addition, there were statistically significant differences in SANE (mean difference, MD = 3.26, 95% confidence intervals, 95%CI 0.77, 5.76, P = 0.01, I2 = 13%) and VAS for pain (MD = -0.17, 95%CI -0.32, -0.02, P = 0.02, I2 = 0%) in the group using the SA technique compared with the traditional surgery group without SA. However, in terms of KT-1000 anteroposterior knee laxity, the traditional surgery group without SA was better than the group with SA (MD = 0.31, 95%CI 0.03, 0.59, P = 0.03, I2 = 0%).

CONCLUSIONS

On the basis of current evidence, we do not believe that, compared with isolated traditional surgical methods, additional SA can significantly improve patients' functional scores and help patients heal.

Anterior Cruciate Ligament Reconstruction Augmentation With Bone Marrow Aspirate Concentrate, Demineralized Bone Matrix, and Suture Tape Shows No Difference in Outcomes-But Faster Functional Recovery-Versus Non-augmented Anterior Cruciate Ligament Reconstruction

PURPOSE

To compare outcomes after anterior cruciate ligament reconstruction (ACLR) with bone marrow aspirate concentrate (BMAC), demineralized bone matrix (DBM), and suture tape augmentation (STA) versus ACLR without biological augmentation or STA.

METHODS

We performed a prospective randomized controlled trial at a single institution to compare ACLR with BMAC, DBM, and STA (group A) versus ACLR without biological augmentation or STA (group NA). The study sought to include 100 patients. Skeletally mature patients younger than 25 years received quadriceps tendon autograft, whereas patients aged 25 years or older underwent allograft ACLR with an all-inside technique. Patients with concomitant meniscal pathologies were included. The primary outcomes compared were range of motion (ROM), limb symmetry, and patient-reported outcomes. Secondary outcomes included radiographic outcomes and surgical complications. Univariate and mixed-model regression analyses were used to compare outcomes.

RESULTS

Fifty-nine patients were included (29 patients in group A [11 female patients, 38%] and 30 patients in group NA [15 female patients, 50%]). Early ROM at 6 weeks (125° of flexion vs 109° of flexion, P < .0001) and limb symmetry at 12 weeks (80.6% vs 36.7% [delta, 43.9%], P < .001) were significantly improved in group A. At 2 years, International Knee Documentation Committee scores were similar (91.1 ± 12.7 vs 85.3 ± 10.8, P = .109). Quality-of-life subscores of the Knee Injury and Osteoarthritis Outcome Score were significantly enhanced in group A (85.2 ± 20.9 vs 72.1 ± 20.4, P = .042). In 22 patients (12 in group A and 10 in group NA), computed tomography scans were obtained at 6 months to compare bone tunnel healing. Overall, the mean increase in bone tunnel diameter was significantly smaller in group A than in group NA. No difference in graft rerupture or reoperation rate was observed. Reoperations were performed for stiffness in 7 of 59 patients (11.9%) (3 [10%] in group A vs 4 [13%] in group NA; P > .999).

CONCLUSIONS

There were no differences in International Knee Documentation Committee scores between groups at 2-year follow-up. Functional outcomes including early ROM and limb symmetry were significantly improved in patients who received ACLR with BMAC, DBM, and STA.

LEVEL OF EVIDENCE

Level II, randomized controlled trial.

Editorial Commentary: Suture Tape Augmentation Enhances Recovery After Anterior Cruciate Ligament Surgery and Is Cost-Effective, While Biologic Augmentation Requires Well-Powered Controlled Trials

Adding a biologic "mix" to facilitate anterior cruciate ligament (ACL) graft healing in bone tunnels is a promising option. Of course, optimization of graft healing in the femoral and tibial tunnels may or may not translate into a better biologic ACL graft. Specifically, after biologic tunnel augmentation, does the graft itself revascularize and remodel more rapidly to allow early return to sport earlier, which could justify the increased cost of biologic augmentation? This remains an unknown. While biologics require further investigation, what is known is that suture tape augmentation protects ACL grafts at higher loads by increasing construct stiffness to avoid elongation, whereas most low loads enhancing graft incorporation and healing are experienced by the grafts. Clinically, recent research shows that suture tape augmentation of ACL quadriceps autograft (without biologics) in young athletes (with an average age of 17) showed no graft retears at a 3-year follow-up and 90% return to sport, and suture tape augmentation is inexpensive.

Satisfactory patient reported outcomes at five years following primary repair with suture tape augmentation for anterior talofibular ligament injury

The Brostrom technique is widely accepted as the gold standard surgical intervention for the treatment of chronic lateral ankle instability. Concerns with persistent postoperative instability, incomplete restoration of preinjury biomechanical strength, and variable return-to-sport rates have, however, led to growing interest in novel augmentation procedures. Suture tape augmentation, which reinforces the anterior talofibular ligament and acts as a secondary stabilizer, is one such method. This study assesses 5-year patient-reported outcomes of primary repair with suture tape augmentation for anterior talofibular ligament injuries. Seventy-seven patients undergoing anterior talofibular ligament repair with suture tape augmentation were prospectively followed for at least 5-years. The visual analogue scale for pain (VAS), veteran rands 12 (VR-12) score, functional foot index (FFI), and the foot and ankle ability measure sports subscale (FAAM-S) were assessed at baseline, 2-year follow-up and 5-year follow-up. Of the seventy-seven patients initially included, sixty-eight (88.3%) completed follow-up. The median VAS, VR-12, FFI, and FAAM-S scores all demonstrated significant improvement at both 2-year and 5-year follow-up, compared to preoperative baseline. Only the FFI demonstrated improvement between the 2-year and 5-year follow-up timepoints. In conclusion, primary repair with suture tape augmentation for anterior talofibular ligament injury demonstrates satisfactory patient-reported outcomes at a minimum of 5-year follow-up. These results suggest that this technique should be considered as an alternative to conventional Brostrom repair for treatment of lateral ankle instability.

Meniscal repair with concomitant suture-augmented ACL repair versus reconstruction: a retrospective cohort study

INTRODUCTION

This study evaluated patient-reported outcome measures (PROM) and reinjury rates in patients undergoing meniscal repair with concomitant suture-augmented (SA) anterior cruciate ligament reconstruction (ACLR) or repair (ACLr).

MATERIALS AND METHODS

We performed a retrospective cohort study of patients who underwent concomitant meniscus and ACL procedures by a single surgeon between 2015 and 2021. Inclusion criteria were meniscal repair with concomitant SA ACLR or SA ACLr, at least two years of follow-up, and participation in postoperative PROM surveys. Exclusion criteria were concomitant meniscectomy, multiligament repair or reconstruction, or other concomitant procedures at the time of the index operation. After a minimum of two years of follow-up, data was collected on reinjury and patient reported outcome measures, including Knee Injury and Osteoarthritis Outcome Score (KOOS), Single Assessment Numeric Evaluation (SANE), Visual Analog Pain Scale, and Veterans Rand 12 Item Survey (VR-12).

RESULTS

39 total patients were identified, 12 ACL repairs and 27 ACL reconstructions. 6 patients were lost to follow-up, with 10 patients in the ACLr cohort and 23 patients in the ACLR cohort included in the study. Meniscus tear laterality was not significantly different between the cohorts (p = 0.3828). There were two meniscal repair failures in the ACLr cohort compared to one in the ACLR cohort (p = 0.2117). There was one ACL reinjury in the ACLr cohort compared to zero reinjuries in the ACLR cohort (p = 0.3030). In a univariate analysis of PROMs, there were no significant differences in postoperative KOOS (p = 0.3308), VAS (p = 0.9955), SANE (p = 0.3449), VR-12M (p = 0.4705), or VR-12P (p = 0.7903) scores between the cohorts. In a multivariable analysis controlling for age, sex, BMI, meniscus tear laterality, and meniscus tear pattern, choice of ACL procedure was not a significant predictor of any postoperative PROM. 23 total patients, 6 ACL repairs and 17 ACL reconstructions had preoperative data available and were evaluated for changes in PROMs after surgery. There were clinically significant improvements in KOOS and SANE scores in both cohorts postoperatively.

CONCLUSION

In this cohort of patients, meniscal repair with SA ACLr was not inferior to meniscal repair with SA ACLR at two years of follow-up.

Anterior Cruciate Ligament Reconstruction: Common Intraoperative Mistakes and Techniques for Error Recovery

PURPOSE OF REVIEW

Anterior cruciate ligament (ACL) reconstruction is a commonly performed procedure among general orthopedists, and is a logged procedure required for graduation from accredited orthopaedic residency programs.

RECENT FINDINGS

ACL reconstruction surgery has a number of critical steps, and intraoperative errors can significantly impact the success rate and morbidity of this operation. Technical errors are frequently cited as some of the most common reasons for ACL reconstruction failure. This narrative review provides low-volume surgeons and trainees with an overview of the common errors that can be made during the critical steps of an ACL reconstruction procedure. We suggest technical points for avoiding commonly-encountered errors and provide a description of evidence-supported error recovery techniques to address these errors if they occur intraoperatively. These key steps include femoral tunnel creation, tibial tunnel creation, graft harvest and preparation, and graft fixation within the tunnels. We discuss a number of primary and backup fixation strategies as well as all commonly used autografts (bone-patellar tendon-bone, hamstring, and quadriceps tendon). Additionally, we provide a brief overview on address intra-operative graft contamination citing currently available evidence.

Chronic reactive synovitis in patients undergoing ACL reconstruction and augmentation with tape-type sutures

Introduction

Arthroscopic Anterior Cruciate Ligament Reconstruction (ACLR) with internal bracing and augmentation using tape-type sutures (TTS) has gained popularity due to its biomechanical advantages. However, concerns have emerged regarding chronic reactive synovitis, which can lead to graft failure and the need for revision surgery. The purpose of this research is to determine the prevalence of chronic reactive synovitis after TTS-reinforced ACLR.

Materials and methods

A retrospective review was conducted on a series of 84 patients who underwent arthroscopic ACL reconstruction with FiberTape or SutureTape augmentation, performed by a single surgeon in the year 2019.

Results

Of the 84 patients analyzed, 17 presented with at least two or more symptoms, including persistent instability, knee pain, swelling, stiffness, and local rise in temperature, within 3-45 months post-surgery. All required secondary surgery, either for synovectomy, and tape removal (8 cases) or revision ACLR (9 cases). Intraoperative histopathological analysis confirmed the diagnosis of reactive synovitis due to foreign body reaction. One year after the secondary surgery, all 17 knees showed satisfactory results. None of the patients experienced the pain, swelling, or instability that they had before the secondary surgery.

Conclusion

Foreign body synovitis was found in 17 symptomatic patients out of 84 (20.2 %) who underwent ACLR with TTS reinforcement one year. While this study does not establish a direct causal link between tape-type sutures and the development of synovitis, it emphasizes the significance of remaining vigilant for impending reactive synovitis as a complication, given the potential exposure of the knee to foreign body material.

Level of evidence

Level IV (Retrospective case series without a comparison group).

All-Inside Anterior Cruciate Ligament Reconstruction Using Full-Thickness All-Soft-Tissue Quadriceps Tendon Autograft With Independent Suture Tape Augmentation

The anterior cruciate ligament (ACL) is the most frequently injured knee ligament that requires surgical intervention. Surgical options to address ACL ruptures include reconstruction using autograft or allograft or performing primary repair. Subsequent ACL graft failure is a significant postoperative concern in the younger patient population. The addition of suture tape to the final construct is thought to protect the graft during moments of high stress by increasing graft stiffness under high load and preventing substantial graft elongation. Given the normal anatomic lengthening of the ACL from knee flexion to full extension, final fixation of both the suture tape and the graft is done with the knee hyperextended to avoid overconstraint. The use of adjustable loop fixation for both femoral and tibial fixation with the all-inside technique allows the graft to be retensioned after final suture tape fixation and subsequent knee cycling. This ensures that the suture tape is slightly laxer than the graft so that the graft experiences loads that are essential for its healing, with the suture tape sharing the load only during times of high stress.

A Technique of Arthroscopic Primary Anterior Cruciate Ligament Repair With Polyester Suture Tape Augmentation

Restoring anterior cruciate ligament (ACL) function after a rupture is critical for reducing long-term knee damage. Primary reconstruction is well established as a golden standard for treatment of complete ACL tear. Nevertheless, carefully selected patients can substantially benefit from a primary repair in comparison to reconstruction. We present a technique of arthroscopic primary ACL repair with polyester suture tape augmentation. Our method expands the spectrum of ACL repair techniques by creating a comfortable pulley-like system of tensioning the ligament and suture tape with a cortical button-suture construct.

Combining an internal tension relieving technique with anterior cruciate ligament reconstruction (ACLR) reduces graft failure rate and improves functional outcomes: a systematic review and meta-analysis

PURPOSE

Graft rupture is a significant cause of graft failure in anterior cruciate ligament reconstruction (ACLR). To address this issue, clinicians have combined the internal tension relieving technique (ITRT) with ACLR to improve graft stiffness, aiming to reduce the risk of graft failure. The purpose of this study is to compare the graft failure rates and clinical functional outcomes between ITRT-assisted ACLR and conventional ACLR.

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a search was conducted in databases including Ovid, PubMed, Web of Science, Embase, Cochrane Library, Wanfang Data, CNKI, and VIP Medical Database for clinical controlled trials comparing the ITRT combined with ACLR to conventional ACLR. The search period spanned from the establishment of the databases to September 2024. Studies meeting the inclusion and exclusion criteria were selected, with two independent reviewers conducting literature screening, quality assessment, and data extraction. Data analysis was performed using RevMan 5.4 software. The evaluated outcomes included graft failure rate, Lysholm Knee Scoring Scale, Tegner activity score, Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score, Visual Analog Scale (VAS) score, Single Assessment Numeric Evaluation (SANE), return to sport (RTS) rate, and knee joint laxity.

RESULTS

A total of 11 studies were included in the final analysis, with 1,339 patients (592 patients with ITRT-assisted ACLR and 747 patients with conventional ACLR). The combined analysis results indicated that, compared to conventional ACLR, ITRT-assisted ACLR showed significant advantages in reducing graft failure rates (RR = 0.44; 95% CI: 0.23, 0.83; P = 0.01), increasing return-to-sport rates (MD = 1.75; 95% CI: 1.05, 2.91; P = 0.03), and improving knee scores (including KOOS score and Tegner activity score) (all P values < 0.05). However, no significant differences were observed between the two approaches in terms of Lysholm knee score, VAS score, IKDC score, and knee joint laxity.

CONCLUSIONS

This meta-analysis highlighted the significance and superiority of combining ITRT with ACLR compared to conventional ACLR, particularly in reducing graft failure rate and improving knee function outcomes. The ITRT-assisted ACLR procedure may represent the optimal approach for minimizing graft failure. However, given the limitations of short-term follow-up and reliance on retrospective studies, more randomized controlled trials and longer follow-up periods are needed to further evaluate the long-term graft failure rates and functional outcomes.

Primary All-Soft Tissue Quadriceps Tendon Autograft Anterior Cruciate Ligament Reconstruction With Suture Tape Augmentation Resulted in Satisfactory Patient Outcomes and a Low Graft Failure Rate in High School and Collegiate Athletes

PURPOSE

To evaluate ≥2-year patient outcomes after primary all-soft tissue quadriceps tendon autograft (ASTQ) anterior cruciate ligament reconstruction (ACLR) with suture tape augmentation (STA) in skeletally mature high school and collegiate athletes.

METHODS

All high school and collegiate athletes who underwent primary ASTQ ACLR with STA with a minimum of 2-year follow-up were analyzed retrospectively. Patients were administered validated patient-reported outcome measures (PROMs) pre- and postoperatively. The minimal clinically important difference was calculated for each PROM based on this study population and applied to the individual patient. Return to sport, subsequent surgical intervention including contralateral ACLR, and KT-1000 arthrometer measurements for knee laxity were collected. Complications were assessed by physical examination, radiologic studies, or obtained via telephone.

RESULTS

In total, 60 patients were included in the final data analysis, with a mean age of 16.8 years (95% confidence interval 13-23) and mean final follow-up of 37.1 months (95% confidence interval 33.1-41.1). Twelve patients (20%) required subsequent surgery on the ipsilateral knee, which included 7 patients having a subsequent meniscal procedure and 3 patients who underwent arthrolysis. None sustained a graft failure, and 6 patients sustained a contralateral ACL injury necessitating surgery. All PROMs improved at the final follow-up (P < .001). In addition, KT-1000 arthrometer measurements significantly improved postoperatively at 1-year clinical follow-up (P < .001). Most patients obtained the minimal clinically important difference thresholds for each PROM at the final follow-up. There were 48 patients (80%) who participated in pivoting sports. The return-to-sport rate at same level was 54 patients (90%), with 6 patients (10%) not returning to the same level because of graduation.

CONCLUSIONS

ASTQ ACLR with STA in a young athletic patient population may result in a low graft failure rate while maintaining satisfactory patient outcomes at short-term follow-up, including a return to sport at the same level of 90%.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Arthroscopic ACL repair with suture tape augmentation: clinical, functional, and gait analysis outcomes at minimum 3-year follow-up

INTRODUCTION

Recent advancements in surgical techniques have led to renewed interest in ACL repair, particularly for acute, proximal tears. Suture tape augmentation (STA) has emerged as a promising technique to support ACL healing while preserving native tissue and potentially improving outcomes. This study aims to evaluate the outcomes of ACL repair with STA in patients with acute, proximal ACL tears.

METHODS

We retrospectively reviewed patients who underwent ACL repair with STA between June 2018 and October 2020. Inclusion criteria were acute (< 6 weeks) ACL rupture, Sherman type I tears, and minimum follow-up of 3 years. Exclusion criteria included mid-substance or distal ACL tears and previous knee surgeries. Clinical evaluation involved stability tests, PROMs, and gait analysis using Prokin WalkerView. Second-look arthroscopy and histological analysis were conducted on a subset of patients.

RESULTS

Twelve consecutive patients (7 males and 5 females) with a mean age of 27.4 ± 7.9 years and mean BMI of 23.3 ± 1.6 kg/m2 were included. Time to operation was 19.5 ± 8.7 days. Mean follow-up duration was 53.2 ± 9.4 months. One patient experienced a traumatic re-rupture. One had a contralateral ACL tear and one experienced hardware irritation. Clinical tests were negative for instability in all patients. Post-operative IKDC, Lysholm, and FJS-12 scores showed significant improvement (p < 0.001). All patients (100%) achieved minimal clinically important difference for all PROMs. Walking gait analysis revealed high symmetry indices for range of motion (93.50%) and step length (95.80%) with near symmetrical loading. Second-look arthroscopy showed intact repairs with healthy tissue morphology and integration. Histology revealed increased cellularity, high nuclear density, and preservation of vascular and neural components indicated by CD34 and S-100 markers.

CONCLUSIONS

Arthroscopic ACL repair with STA provides favourable clinical, functional, and histological outcomes with low re-rupture rates when performed on acute, proximal ACL tears. This technique demonstrates fair-to-good PROMs, functional stability, and near-normal gait parameters.

Anterior Cruciate Ligament Reconstruction with Internal Brace Augmentation Results in Fewer Reruptures Compared to Reconstruction without Augmentation

Objective  To compare the clinical outcomes of anterior cruciate ligament (ACL) reconstruction using autografts with and without internal brace augmentation. Methods  Data from patients who underwent ACL reconstruction with hamstring and quadriceps tendon autografts, with a minimum follow-up of one year, with or without internal brace augmentation were collected prospectively analyzed retrospectively. The Lysholm and Tegner functional scores were collected before and after surgery, as well as data on postoperative complications. For the comparison of means of the two groups, we used the Student t test or the Mann-Whitney non-parametric test, when the assumption of normality of the data was rejected. Results  In total, 55 patients underwent ACL reconstruction with internal brace augmentation and another 55 patients underwent ACL reconstruction without internal brace augmentation. The patients were aged between 16 and 63 years (mean of 32.7 ± 11.4 years). A total of 62 patients (56.4%) underwent ACL reconstruction with hamstring graft, and 19 patients (17.3%), with quadriceps tendon graft, with a diameter variation of 7 mm to 11 mm (mean of 8.95 ± 0.83 mm). The postoperative scores did not differ between the groups ( p  > 0.05). Regarding the group submitted to ACL reconstruction with internal brace augmentation, 4 patients had complications: @ cases of arthrofibrosis, 2 (3.7%); 1 case of rerupture (1.8%); and 1 case of thrombosis (1.8%). In the group submitted to ACL reconstruction without augmentation, 7 patients manifested complications: 2 cases of arthrofibrosis (3.9%); 4 cases of rerupture (7.3%); and 1 case of infection (2%). Conclusion  The results of the present study show that fewer cases of ACL rerupture were observed after reconstruction with internal brace augmentation when compared with ACL reconstruction without augmentation, although no differences in functional scores were found.

Arthroscopic Anatomic Anterior Cruciate Ligament Primary Repair Restores Anterior Tibial Translation Intraoperatively at Time Zero With No Additional Effect of Suture Augmentation

PURPOSE

To intraoperatively evaluate the ability of anterior cruciate ligament (ACL) primary repair (ACLPR) to restore anterior tibial translation (ATT) at time zero and to assess the influence of additional suture augmentation (SA) on ATT.

METHODS

Patients with proximal ACL tears undergoing arthroscopic ACLPR with dual-suture anchor fixation were included in this time-zero clinical study. Laxity measurements were taken with a digital arthrometer to evaluate ATT stability preoperatively in the office (T0) as a standardized diagnostic tool, preoperatively under anesthesia (T1), at time zero intraoperatively after ACLPR but prior to SA fixation (T2), and after SA fixation (T3).

RESULTS

A total of 27 patients (mean age ± standard deviation [SD], 35.1 ± 12.0 years) with proximal ACL tears and significant preoperative (T0) ATT side-to-side differences (SSDs) (mean ± SD, 4.1 ± 1.5 mm) were evaluated. ACLPR was shown to restore ATT SSD at time zero (mean ± SD, 0.2 ± 1.1 mm) given that a significant reduction in ATT SSD (mean difference ± standard error, -4.7 ± 0.21 mm; P < .001) was achieved when comparing preoperative and intraoperative measurements after separate refixation of both ACL bundles with suture anchors. Additional SA fixation did not further decrease ATT when comparing measurements of the ipsilateral leg after ACL refixation and after SA fixation (mean difference ± SD, 0.03 ± 0.22 mm; P = .496).

CONCLUSIONS

ACLPR with dual-suture anchor fixation restores time-zero ATT laxity in adults with proximal ACL tears. Additional SA fixation in full knee extension does not further decrease ATT.

CLINICAL RELEVANCE

This study provides important information about the effectiveness of ACLPR in restoring ATT. SA with the knee fixed in full knee extension does not further decrease ATT; therefore, augmentation may not lead to overconstraint of the knee or stress shielding of the repaired ACL.

Outcomes of medial collateral ligament reconstruction with suture-augmented semitendinosus autograft

PURPOSE

This study evaluates patient-reported outcomes among patients who underwent medial collateral ligament (MCL) reconstruction with suture-augmented semitendinosus autograft (SASA).

METHODS

Patients who underwent SASA MCL reconstruction between 2017 and 2022 participated in preoperative and postoperative surveys for patient-reported outcomes: Visual Analog Pain Scale (VAS), Knee Injury and Osteoarthritis Outcomes Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Single Assessment Numeric Evaluation (SANE), Marx Activity Rating Scale (MARS), and Veterans Rand 12 (VR-12). Paired t-tests were performed to compare preoperative and postoperative scores. Postoperative complications were analyzed for all patients.

RESULTS

A total of 19 operations were identified during the study period, and 16 patients were included in the study. Patients reported significant decreases in VAS (mean [95% CI] of -3.86 [-6.09, -1.63], p = 0.0022) and WOMAC (-24.87 [-40.30, -9.4], p = 0.0037) scores postoperatively. Patients also reported significant increases in KOOS (22.60 [9.79, 35.40], p = 0.0019), SANE (38.06 [18.83, 57.27], p = 0.0007), and VR-12 Physical (14.32 [6.38, 22.27], p = 0.0017) scores. Patients did not report significant changes in MARS (0.87 [-1.88, 3.63], p = 0.5081) or VR-12 Mental (-2.90 [-9.37, 3.56], p = 0.3516) scores after surgery. Four patients required reoperation for either arthrofibrosis (n = 3) or ACL reinjury following a multiligament procedure that did not require revision to the MCL reconstruction (n = 1).

CONCLUSION

In this cohort of patients undergoing MCL reconstruction with SASA, patients reported significant improvement in functional outcomes and reduction in pain postoperatively. SASA is a safe and effective technique for MCL reconstruction.

Association of suture augmentation with graft failure and clinical outcomes following anterior cruciate ligament reconstruction: A systematic review and meta-analysis of comparative studies with a minimum 2-year follow-up

PURPOSE

To compare graft failure, nonrevision reoperation, complication, patient-reported outcome measures (PROMs) and return to sports (RTS) between patients who underwent anterior cruciate ligament reconstruction (ACLR) with and without suture augmentation (SA).

METHODS

A systematic search was performed on PubMed, Cochrane, Embase and Web of Science databases from the inception of databases to 18 April 2024, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies comparing clinical outcomes of SA- and standard ACLR with a minimum 2-year follow-up were included. Data extraction and quality appraisal were performed by two researchers independently.

RESULTS

Eight retrospective cohort studies were included, with a total of 408 patients receiving SA-ACLR and 443 patients receiving standard ACLR. A meta-analysis of graft failure demonstrated a 62% relative risk reduction (RR [risk ratio], 0.38 [95% confidence interval {CI}, 0.19-0.73]; p = .004) in those receiving SA-ACLR compared with standard ACLR. An age-related heterogeneity in graft failure reduction was detected in the subgroup analysis, which was more pronounced in studies with mean ages of <20 years compared with ≥20 years (p = .05; I2 = 73.9%). No significant difference was observed in nonrevision reoperation or complication rates. No clinically relevant difference was observed in PROMs. SA-ACLR was associated with a significantly higher RTS rate compared with the standard ACLR (RR, 1.12 [95% CI, 1.00-1.24]; p = .04), whereas no significant difference was observed in time to RTS.

CONCLUSION

SA-ACLR is associated with a reduced graft failure rate and increased RTS rate compared with standard ACLR without additional reoperations or complications. However, confidence in the evidence is limited by substantial heterogeneity. Future studies with a higher level of evidence are warranted to validate the benefit of SA and to determine the indication for different risk populations.

LEVEL OF EVIDENCE

Level III.

Insufficient Evidence for Anterior Cruciate Ligament Reconstruction Utilizing Suture Tape Augmentation: A Systematic Review of Clinical Outcomes at Minimum 1-Year Follow-Up

PURPOSE

To perform a systematic review of clinical studies to directly compare clinical outcomes of patients undergoing anterior cruciate ligament reconstruction (ACLR) with versus without suture tape (ST) augmentation.

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify comparative studies directly comparing outcomes of ACLR with versus without ST augmentation with a minimum follow-up of 12 months. The search terms used were anterior cruciate ligament suture tape. Patients were evaluated based on graft failure rates, return to sport (RTS), anteroposterior (AP) laxity, and patient-reported outcomes (PROs).

RESULTS

Five studies (all Level III) met inclusion criteria, including a total of 246 patients undergoing ACLR with ST augmentation (SA group) and 282 patients undergoing ACLR without augmentation (control group). Patient age ranged from 14.9 to 29.7 years. The mean follow-up time ranged from 24.0 to 48.6 months. The mean body mass index ranged from 25.3 to 26.3 kg/m2 and the overall percentage of males ranged from 43.4% to 69.0%. Overall, the graft failure rate ranged from 1.0% to 25.0% in the SA group and 8.0% to 20.0% in the control group. Among the studies that reported RTS rates, the rate ranged from 69.2% to 88.9% in the SA group and 51.5% to 87.5% in the control group. Among all PROs, 2 studies found a significant difference in the Tegner score favoring the SA group. Otherwise, no significant differences were found between groups in terms of PROs. No significant differences in AP laxity were found between groups within any particular study. There was heterogeneity between studies regarding surgical techniques, postoperative rehabilitation protocols, and reported PROs.

CONCLUSIONS

There is insufficient evidence to suggest that patients undergoing ACLR with ST augmentation may experience favorable clinical outcomes compared with ACLR alone.

LEVEL OF EVIDENCE

Level III, systematic review of Level III studies.

Risk for Revision ACLR After Primary All-Inside Quadrupled Semitendinosus Hamstring Tendon Autograft ACLR With Independent Suture Tape Augmentation: A Retrospective Cohort Study

Background

The rate of failed anterior cruciate ligament reconstruction (ACLR) remains high in the younger and more active patient populations. Suture tape augmentation (STA) in addition to ACLR may reduce the risk for revision surgery.

Purpose/Hypothesis

The purpose of this study was to compare patient outcomes between patients who underwent primary all-inside quadrupled semitendinosus hamstring tendon autograft (QST-HTA) ACLR with and without STA. It was hypothesized that the STA cohort would demonstrate a lower incidence of subsequent revision ACLR while maintaining comparable patient-reported outcomes.

Study Design

Cohort study; Level of evidence, 3.

Methods

All patients ≤40 years of age who received primary all-inside QST-HTA ACLR with and without independent STA augmentation were identified. The following validated patient-reported outcome measures (PROMs) were collected: visual analog scale for pain, Single Assessment Numeric Evaluation, Knee injury and Osteoarthritis Outcome Score subscales, and Tegner activity scale. KT-1000 arthrometer measurements were collected pre- and postoperatively. Cox proportional hazards model and nominal logistic regression analysis were used to assess additional variables associated with revision ACLR.

Results

A total of 104 patients with a mean age of <22 years were included in the final data analysis (STA: 36 patients; control: 68 patients). Significantly fewer patients in the STA group sustained a graft failure necessitating revision surgery at the final follow-up (5.6% vs 24%; relative risk, 0.24 [95% CI, 0.06-0.97]; P = .017). Four-year graft survival was significantly higher in the STA group (97.2% vs 82.4%; P = .031). All PROMs significantly improved postoperatively except for Tegner levels, which decreased in both groups compared with their preinjury levels (P < .001). Return to sports was similar in both groups with >70% of patients returning to their previous level of competition. Regression analysis demonstrated increased risk for revision ACLR in younger patients, high school athletes, and those with higher postoperative activity levels.

Conclusion

QST-HTA ACLR with STA was associated with reduced risk for revision ACLR compared with nonaugmented QST-HTA ACLR in this young patient population. Furthermore, the addition of suture tape did not appear to affect postoperative patient-reported and return-to-sports outcomes.

Less Subsequent Revision Anterior Cruciate Ligament Reconstruction Following Primary Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction with Suture Tape Augmentation-A Retrospective Comparative Therapeutic Trial With 5-Year Follow-Up

PURPOSE

To investigate patient outcomes, including revision rate, following primary bone patellar-tendon bone autograft (BPTB) anterior cruciate ligament reconstruction (ACLR) with and without suture tape augmentation (STA) in a young and active cohort.

METHODS

All eligible patients who received primary BPTB ACLR with a minimum of 2-year follow-up were included in this retrospective cohort study. All patients receiving STA were augmented with the same device. Patients completed the following patient-reported outcome measures (PROMs): the visual analog scale, the Single Assessment Numeric Evaluation, the Knee Injury and Osteoarthritis Outcome Score subscales, and the Tegner activity scale. Anteroposterior knee laxity was assessed using a KT-1000 arthrometer preoperatively and 1-year postoperatively. Posterior tibial slope, femoral tunnel angle, and tibial tunnel placement were calculated for all patients. Subsequent surgical interventions and return to sport (RTS) were obtained from each patient.

RESULTS

One hundred fourteen patients (52 BPTB ACLR with STA, 62 traditional BPTB ACLR) with a mean patient age <19 years and a mean final follow-up of ≥5 years were included. Compared with the control group, the STA group demonstrated significantly less subsequent revision ACLR (0 vs. 5, P = .036). All PROMs and KT-1000 measurements improved at final follow-up (P < .001) and were comparable between groups. There were no differences seen in either posterior tibial slope or graft tunnel placement between groups. More than 85% of the patients were able to return to the sport that led to their injury at full capacity with no differences seen in RTS rate, time to RTS, or level of competition between groups.

CONCLUSIONS

Compared with traditional BPTB ACLR, additional STA appeared to safely and effectively lead to less subsequent revision ACLR while maintaining acceptable PROMs and objective joint laxity measurements in a young and active patient population.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Editorial Commentary: Anterior Cruciate Ligament Repair or Reconstruction With Internal Bracing, for Properly Indicated Patients, Is Safe, Biocompatible, and Biomimetic

Anterior cruciate ligament (ACL) reconstruction with internal bracing (IB)-and ACL repair with IB when indicated-reduces graft or repair failure. IB is safe and protects ligament reconstructions and repairs. The IB construct should not be misunderstood as a synthetic ligament. To be effective, suture tape must be independently secured with the knee in full extension, reflecting the terminal length of the ACL. Regardless of graft type, the graft must be cyclically tensioned independent of the IB to allow for creep, and when properly performed, this significantly increases the ultimate tensile strength of the construct and reduces graft elongation, without stress shielding. Thus, the generic term "suture augmentation" may be misleading because the successful results reported apply to the IB technique. In our experience, the failure rate after ACL reconstruction with IB is 1% at the 5-year follow-up period. Notably, these results were achieved without an additional lateral extra-articular procedure.

Analysis of Graft Types Augmented With an Internal Brace for ACL Reconstruction: A Systematic Review

BACKGROUND

New techniques are being developed to decrease the failure rate of anterior cruciate ligament (ACL) grafts and prevent revision surgery. One such technique involves high-strength suture tape (ST), also referred to as internal bracing. Recent literature has highlighted the use of ST for ACL reconstruction, but no study has compared ST augmentation between graft types.

PURPOSE

To compare the use of ST augmentation for ACL reconstruction based on the type of graft used (ie, bone-patellar tendon-bone [BPTB], quadriceps, hamstring).

STUDY DESIGN

Systematic review; Level of evidence, 5.

METHODS

An online search of multiple databases was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and was completed April 2022 to identify studies related to ST augmentation of ACL grafts.

RESULTS

Of 926 studies identified, 10 met inclusion criteria. Five studies (50%) used hamstring tendon (HT), 3 (30%) used quadriceps tendon (QT), 1 (10%) used BPTB, and 1 (10%) used both HT and QT grafts. HT autografts augmented with ST had decreased dynamic and peak elongation (15%-56%), increased load to failure, and increased initial and final dynamic stiffness compared with controls. There was no significant difference in postoperative physical examination findings (range of motion, Lachman, pivot shift), except that ST-augmented grafts had significantly less laxity after surgery compared with HT alone (0.8 vs 1.9 mm; P < .05). QT allografts with ST augmentation showed increased graft strength. Human QT autograft studies showed higher Knee injury and Osteoarthritis Outcome Score scores compared with controls. BPTB allografts with ST augmentation had decreased cyclic displacement by 31% (P = .015) and increased load (758 ± 128 N; P < .001) and stiffness (156 ± 23 N/mm; P = .003) compared with nonaugmented groups. The complication rate was low or showed no increase in the ST augmentation groups compared with control groups.

CONCLUSION

HT, QT, and BPTB grafts augmented with ST demonstrate an effective method for ACL reconstruction. All graft types with ST augmentation showed no evidence of clinical disadvantage, with some studies indicating significant biomechanical or clinical advantages compared with conventional ACL reconstruction.

Bone-Patellar Tendon-Bone Augmentation With Gracilis Tendon: The Bone-Patellar Tendon-Bone Plus Technique

The bone-patellar tendon-bone (BPTB) autograft or allograft is a well-established option for primary or revision anterior cruciate ligament (ACL) reconstruction. However, although the length and width of the graft are relatively consistent, its thickness is unpredictable and can impact the biomechanical properties of the ACL graft. This technical note describes a technique for arthroscopic ACL reconstruction called the "BPTB-plus" technique, which consists of a BPTB graft augmented by the gracilis tendon.

Clinical efficacy and kinematic analysis of Chinese knotting technique-assisted posterior cruciate ligament reconstruction: A retrospective analysis

To investigate the clinical efficacy and knee joint kinematic changes of posterior cruciate ligament (PCL) reconstruction assisted by Chinese knotting technique (CKT). A retrospective analysis was conducted on 88 cases of PCL reconstructive surgery admitted between September 2016 and September 2020. All patients were operated on by the same senior doctor and his team. The patients were divided into 2 groups according to whether the CKT was applied, with 44 cases in each group. Both groups received active rehabilitation treatment after surgery. All patients were followed up for more than 2 years. International knee documentation committee, hospital for special surgery (HSS), and Lysholm scores were used to evaluate the clinical efficacy of the 2 methods at 3, 12, and 24 months after surgery. The motion cycle and kinematic indices of the knee joint were measured by the Opti_Knee three-dimensional motion measurement system before surgery and at 3, 12, and 24 months after surgery. A secondary arthroscopic examination was performed at 12 months after surgery, MAS score was used to evaluate the secondary endoscopic examination of PCL. All the patients had wound healing in stage I without infection. International Knee in both sets Documentation Committee scores, HSS scores and Lysholm scores were gradually improved at all time points (P < .05); compared with the traditional group, the HSS score was higher in the reduction group 12 months after surgery (P < .05), but there was no significant difference at 24 months after surgery. 12 months and 24 months after 3 dimensional motion measurement system using Opti_Knee showed a reduction group before and after displacement and displacement of upper and lower range than the traditional group (P < 0. 05). One year after surgery, the good and good rate of MAS score reduction group was higher than traditional group. CKT assisted PCL reconstruction can improve the subjective function score of the affected knee joint and the results of secondary microscopy. Satisfactory knee kinematic function can be obtained in the early stage, and the anteroposteric relaxation of the knee joint can be reduced.

Additional suture augmentation to anterior cruciate ligament reconstruction with hamstring autografts bring no benefits to clinical results, graft maturation and graft-bone interface healing

BACKGROUND

From the perspective of graft protection and early rehabilitation during the maturation and remodeling phases of graft healing, suture augmentation (SA) for anterior cruciate ligament reconstruction (ACLR) has attracted more and more attention.

STUDY DESIGN

Retrospective study.

PURPOSE

To determine whether the additional SA affects clinical results, graft maturation and graft-bone interface healing during two years follow-up after ACLR.

METHODS

20 ACLRs with additional SA (ACLR-SA group) and 20 ACLRs without additional SA (ACLR group) were performed between January 2020 and December 2021 by the same surgeon and were retrospectively analyzed. Pre- and postoperative International Knee Documentation Committee (IKDC) scores, Lysholm scores, graft failure and reoperation were evaluated. The signal/noise quotient (SNQ) of autografts and the signal intensity of graft-bone interface were analyzed. All 40 patients in ACLR-SA group and ACLR group completed 2-years follow-up.

RESULTS

There was no patient in the two cohorts experienced graft failure and reoperation. The postoperative IKDC and Lysholm scores have been significantly improved compared with preoperative scored in both ACLR-SA group and ACLR group, however, there was no significant difference between two groups. The SNQ of proximal graft of ACLR-SA group (14.78 ± 8.62 vs. 8.1 ± 5.5, p = 0.041) was significantly greater while the grades of graft-bone interface healing of posterior tibial was significantly lower than that of ACLR group at 1-year postoperatively (p = 0.03), respectively. There were no significant differences between the two groups of the SNQ of proximal, distal medial graft segments, and the graft-bone interface healing grades of anterior femoral, posterior femoral, anterior tibial and posterior tibial at other time points (p>0.05).

CONCLUSIONS

The additional SA in ACLR had no effect on IKDC scores, Lysholm scores, graft maturation and graft-bone interface healing at 2-year postoperatively. Our research does not support the routine use of SA in ACLR.

Quadriceps Tendon Autograft ACL Reconstruction With Suture Tape Augmentation: Safe Results Based on Minimum 2-Year Follow-up MRI

Background

The potential intra-articular effects of ≥1 year after anterior cruciate ligament reconstruction (ACLR) with independent suture tape augmentation (STA) are not fully understood.

Purpose

To investigate whether incorporating suture tape in an all-soft tissue quadriceps tendon autograft (QTA) ACLR leads to satisfactory patient outcomes while having no intra-articular side effects as determined by magnetic resonance imaging (MRI).

Study Design

Case series; Level of evidence, 4.

Methods

Included were 25 patients with a mean age of 19.9 years (95% CI, 17.3-22.5 years) who underwent QTA ACLR with STA between 2016 and 2019. All patients underwent MRI at ≥1 year postoperatively and had at least a 2-year follow-up (mean, 28 months [95% CI, 26.5-29.5 months]) that included physical examination with anterior laxity testing with KT-1000 arthrometer, radiographs, and patient-reported outcome measures (PROMs). At the final follow-up, the minimal clinically important difference (MCID) and the Patient Acceptable Symptom State (PASS) for applicable PROMs were applied to each patient. Postoperative graft and joint integrity were assessed using the Howell classification and the MRI Osteoarthritis Knee Score (MOAKS) joint effusion/synovitis grade. The Mann-Whitney U test for continuous variables and the chi-square or the Fisher exact test for categorical variables were used for statistical analyses.

Results

The MRI assessment of the grafts demonstrated intact grafts in all patients. Overall, 96% of patients demonstrated grades 0 or 1 MOAKS for joint effusion/synovitis. All patient outcomes significantly improved from preoperatively to the final follow-up (P < .001), except for the Marx score, which decreased significantly (14.2 [95% CI, 12.7-15.8] vs 9.72 [95% CI, 7.3-12.2]; P = .0014). At least 68% of the patients achieved the MCID threshold, and 92% achieved the PASS threshold for all applicable PROMs.

Conclusion

QTA ACLR with STA did not demonstrate adverse intra-articular changes on MRI at ≥1 year postoperatively. In addition, STA did not appear to negatively affect PROMs.

Primary Anterior Cruciate Ligament Reconstruction with Suture Tape Augmentation: A Case Series of 252 Patients

Anterior cruciate ligament reconstruction (ACLR) using suture tape augmentation to internally brace is a relatively new technique. The primary goal of this study was to prospectively collect patient-reported outcomes (PROs) and surgical history from patients who underwent primary ACLR with internal bracing to determine if internal bracing resulted in a low graft failure rate while maintaining acceptable PROs. A total of 252 patients with a mean age of 23.6 years (95% confidence interval [CI]: 22.1-25.1) and a mean follow-up of 37.9 months (95% CI: 35.8-40.0) were included in this study. Patients who underwent primary ACLR with internal brace augmentation between July 12, 2016 and July 31, 2021 were eligible. A total of 222 patients were contacted via telephone and administered the visual analog scale (VAS), the single assessment numeric evaluation (SANE), the Lysholm knee score scale, and, if applicable, the short version ACL return to sport after injury (SV-ACL-RSI) survey. Additionally, patients were asked to give an updated orthopaedic history. Thirty additional patients were included from either our institution's registry or by completing their surveys in-office or by e-mail. The minimal clinically important difference (MCID) and patient-acceptable symptom states (PASS) were calculated based on our patient population and applied to each individual patient. The patients' electronic health record (EHR) was searched for pre- and postoperative clinical data including KT-1000 arthrometer measurements. Two patients (0.8%) had subsequent graft failures and one patient (0.4%) required a revision surgery. MCID was achieved in 242 patients (96.0%) for the Lysholm, 227 patients (90.1%) for the SANE, and 146 patients (57.9%) for the VAS. PASS was achieved in 214 patients (84.9%) for the Lysholm, 198 patients (78.6%) for the SANE, and 199 (80.0%) patients for the VAS, postoperatively. Of note, 65 patients (25.8%) exceeded the PASS threshold for the VAS preoperatively. A total of 127 patients (84.4%) met the cutoff of ≥60/100 for the SV-ACL-RSI survey postoperatively. Postoperative KT-1000 measurements showed near-identical side-to-side differences at both the 13.6-kg pull and manual maximum pull. When stratifying patients based on age at the time of surgery, it was noted that patients younger than 25 years had significantly higher SANE scores (91.6 [95% CI: 90.2-92.9] vs. 82.6 [95% CI: 79.0-86.2]; p < 0.0001) and lower VAS pain scores (0.7 [95% CI: 0.5-0.8] vs. 1.2 [95% CI: 0.8-1.5]; p = 0.004). Primary ACLR with internal bracing led to acceptable patient outcomes and a graft failure rate of less than 1%. LEVEL OF EVIDENCE:: case series, IV.

Ligamentoplasty in scapholunate instability: short-term results of the "all dorsal scapholunate repair" technique

Injury to the scapholunate complex is the cause of scapholunate instability which can lead to radiocarpal and medio-carpal osteoarthritis. Several ligamentoplasty techniques have been reported for the treatment of chronic scapholunate instability before the osteoarthritis stage. The objective of this study was to assess the short-term results of an "all dorsal scapholunate repair" ligamentoplasty. We report the clinical, radiological and functional results of a retrospective study including 21 patients, operated between June 2019 and December 2020 for a stage 3 or 4 scapholunate instability according to the Garcia Elias classification. With a follow-up of 14.2 months, the pain was 0.1/10 according to the VAS at rest and 4/10 during exercise. Wrist strength was measured at 65% of the opposite side. The flexion-extension range of motion was 105°. Radiologically, there was a reduction of the diastasis and scapholunate angle. Osteolysis areas around the anchors were described in 47% of patients. The mean QuickDASH was 29.2/100, PRWE 24/100 and Mayo wrist score 67.8/100. Eighty-one percent of patients were satisfied. Seventeen patients had returned to work 5.2 months postoperatively. In the case of work-related injury, the functional scores were poorer, with a delayed return to work. This technique provides encouraging results in the short term. Most patients were improved compared to preoperative state. The work-related injury appears to be a poor prognostic factor. A longer-term study is imperative to confirm the maintenance over time of the correction of carpal malalignment and the evolution of the osteolysis areas.Level of evidence: Level IV Retrospective study.

Suture Augmentation of a Four-Strand Semitendinosus Graft Improves Time-Zero Biomechanical Properties

PURPOSE

To compare the time-zero biomechanical properties of hamstring graft preparations with or without suture augmentation for anterior cruciate ligament reconstruction (ACLR) in a full-construct cadaveric model.

METHODS

Hamstring grafts were harvested from 24 fresh frozen human cadavers and prepared in 1 of 3 ways: quadrupled SemiTendinosus (SemiT), and quadrupled SemiT with suture augmentation (SemiT+2.0-mm tape or SemiT+1.3-mm tape; n = 8 per group). Adjustable loop suspensory implants and cortical buttons were used for fixation on a porcine tibia and acrylic block. Testing included force-controlled cyclic loading at 250 N and 400 N followed by load to failure.

RESULTS

The 2 suture augmentation groups had less total elongation and increased stiffness compared to the nonsuture-augmented group (P = .025). The SemiT+2.0-mm tape group had 36% less total elongation and 34% increased stiffness compared to SemiT+1.3mm tape (P < .001).

CONCLUSIONS

Suture augmentation improves construct biomechanics at time zero following hamstring tendon ACLR. Augmentation with 2.0-mm tape suture improves construct biomechanics compared to 1.3-mm tape suture.

CLINICAL RELEVANCE

Independent suture augmentation of a quadrupled SemiT graft improves ACLR construct biomechanics. Outcomes were improved with augmentation using 2.0-mm tape suture compared to 1.3-mm tape suture.

Internal brace augmentation reconstruction versus standard anterior cruciate ligament reconstruction: a randomised controlled clinical trial study protocol

INTRODUCTION

Anterior cruciate ligament (ACL) rupture is one of the most common knee injuries in sports, and the gold standard for treating ACL rupture is tendon graft reconstruction. Internal brace technology is being used nowadays for ligament repair; however, more relevant in vivo clinical evidence is required for using internal brace technology in ACL reconstruction (ACLR). We conducted a randomised controlled trial to investigate the clinical efficacy of internal brace technology in ACLR.

METHODS AND ANALYSIS

This randomised, parallel-controlled trial included patients with ACL rupture who underwent inpatient surgery at the Department of Orthopaedics, Xiangya Hospital, Central South University. Random number table method was used to assign the participants to either the test or the control group. The test group underwent ACLR using the internal brace technique, whereas the control group underwent standard ACLR. Uniform postoperative rehabilitation protocol was used for both the groups. Patient-reported outcomes included preoperative baseline and postoperative recovery at 1, 3, 6, 12 and 24 months. The primary outcome was International Knee Documentation Committee function from baseline (ACL rupture) to 6 months postoperatively. Secondary outcomes included (1) other patient outcome reporting metrics, Lysholm knee score, Knee Injury and Osteoarthritis Outcome Score and Visual Analog Scale; (2) the use of Kneelax3 knee stabiliser to assess knee stability; (3) occurrence of adverse events, such as graft refraction or symptomatic instability, postoperative infection and contralateral injury and (4) magnetic resonance images at 12 and 24 months after ACLR.

ETHICS AND DISSEMINATION

This trial was approved by the Medical Ethics Committee of the Xiangya Hospital of Central South University on 26 October 2021. Data will be published in peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2200057526.

There is no difference in the efficacy of anterior cruciate ligament reconstruction using autograft combined with or without ligament augmentation: a systematic review and meta-analysis

PURPOSE

This study aims to determine the efficacy of anterior cruciate ligament reconstruction (ACLR) using autograft combined with or without ligament augmentation.

METHODS

A computerized search of the databases was conducted, including PubMed, Web of Science, Embase, Scopus and the Cochrane Library. Only prospective or retrospective comparative studies with a minimum 2-year follow-up were considered for inclusion. Two independent reviewers performed data extraction and methodological quality assessment. A Mantel-Haenszel analysis was used for the pooling of results. Sensitivity analysis was performed to maintain the stability of results. The egger test was applied to assess the publication bias.

RESULTS

Fourteen studies were included. The total cohort was 1353 patients (non-augmented group: 763 patients; augmented group: 590 patients). There were three Randomized Controlled Trials (RCTs, Level I), six retrospective comparative studies (Level III) and five case-control studies (Level III). The follow-up rate was ≥ 88% and the follow-up periods were ≥ 24 months in all included studies. The augmented graft used to compare with autograft included the Ligament Augmentation Device (LAD), the Ligament Advanced Reinforcement System (LARS) artificial ligament, FiberTape, hamstring tendon allograft, degradable poly (urethane urea). No significant differences were observed between the augmented and non-augmented groups regarding postoperative patient-reported outcomes (PROs), including the International Knee Documentation Committee score, Lysholm score and Tegner score, knee laxity, including KT-1000, side-to-side difference, Lachman test and pivot shift and rate of graft failure.

CONCLUSIONS

ACLR using autografts combined with ligament augmentation shows no advantages in PROs, knee laxity and graft failure rate compared with using autografts only.

LEVEL OF EVIDENCE

Level III.

TRIAL REGISTRATION

The research protocol was registered at the PROSPERO database (CRD42022324784).

Outcomes of Anterior Cruciate Ligament Reconstruction With Independently Tensioned Suture Tape Augmentation at 5-Year Follow-up

BACKGROUND

Reconstruction using autograft remains the gold standard surgical treatment for anterior cruciate ligament (ACL) injuries. However, up to 10% to 15% of patients will suffer a graft failure in the future. Cadaveric studies have demonstrated that the addition of suture tape augmentation to ACL autograft constructs can increase graft strength and reduce elongation under cyclical loading.

PURPOSE/HYPOTHESIS

This study aimed to investigate the clinical outcomes and rerupture rates after ACL reconstruction (ACLR) with suture tape augmentation. We hypothesized that augmentation with suture tape would lead to lower rerupture rates.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients undergoing primary ACLR using hamstring or patellar tendon autografts augmented with suture tape between 2015 and 2019 were recruited prospectively. Patients with multiligament injuries or a concomitant lateral extra-articular procedure were excluded. Patients were observed in person for 6 months, and patient-reported outcome measures (PROMs) were collected at 2 and 5 years postoperatively. All patients were contacted, and records were reviewed to determine the incidence of graft failure. PROMs collected were as follows: Knee injury and Osteoarthritis Outcome Score (KOOS), Veterans RAND 12-Item Health Survey (VR-12), Tegner and Marx activity scores, and visual analog scale for pain (VAS).

RESULTS

A total of 97 patients, with a mean age of 34.7 (±13.4) years, were included (76% men; 52 hamstring and 45 patellar tendon grafts). The mean graft diameter was 8 (±1) mm. There was 1 rerupture (1.1%) out of the 90 patients who were contactable at a mean of 5 years postoperatively. Median KOOS scores at 2 years were as follows: Pain, 94; Symptoms, 86; Activities of Daily Living, 99; Sport and Recreation, 82; and Quality of Life, 81. The postoperative scores were significantly higher than the preoperative scores (P < .001). The VR-12 Physical score improved from 43 preoperatively to 55 at 2 years and remained at 56 at 5 years. The VAS pain, Tegner, and Marx scores were 0, 6, and 9, respectively, at 2 years postoperatively. There was no difference in PROMs between graft types.

CONCLUSION

This study demonstrates encouraging results of suture tape augmentation of autograft ACLR for both hamstring and patellar tendon grafts. The failure rate of 1.1% at a mean follow-up of 5 years is lower than published rates for reconstruction, and PROMs results are satisfactory. The technique is safe to use and may permit a return to the preinjury sporting level with a lower chance of reinjury.

Evaluation of biomechanical properties and biocompatibility: are partially absorbable cords eligible for anterior cruciate ligament reconstruction?

Introduction: Independent augmentation technology based on reinforcing devices has been reported to signifi-cantly reduce the elongation behavior of graft and improve knee stability after anterior cruciate ligament reconstruction (ACLR). Using biodegradable devices could reduce the risk of severe inflammatory reactions due to particle accumulation from foreign bodies. Given the limitations of the mechanical properties of biodegradable materials, partially biodegradable composite devices may offer a compromise strategy. Methods: Three types of partially absorbable core-sheath sutures, including low-absorbable cord (LA-C), medium-absorbable cord (MA-C) and high-absorbable cord (HA-C), were braided using unabsorbable ultra-high molecular weight polyethylene (UHMWPE) yarn and absorbable polydioxanone (PDO) monofil-ament bundle based on the desired configuration. The feasibility of these partially absorbable cords were verified by biomechanical testing, material degradation testing, and cell experiments, all performed in vitro. Results: Reinforcement of an 8 mm graft with the cords decreased dynamic elongation by 24%-76%, was positively related to dynamic stiffness, and increased the failure load by 44%-105%, during which LA-C showed maximum enhancement. Human ligament-derived fibroblasts showed good proliferation and vitality on each cord over 2 weeks and aligned themselves in the direction of the fibers, especially the UHMWPE portion. Discussion: This study supports the potential of partially degradable UHMWPE/PDO cords, particularly LA-C, for graft protection. Nervertheless, a higher proportion of biodegradable material results in lower stiffness, which may impair the protective and lead to mechanical instability during degradation.

Clinical and Patient-Reported Functional Outcome of Semitendinosus Autograft Anterior Cruciate Ligament Reconstruction With FiberTape® InternalBrace™ All-Inside Technique: A Prospective Study

AIM

The purpose of this study is to report the early one-year clinical and patient-reported functional outcomes of semitendinosus autograft anterior cruciate ligament reconstruction with the FiberTape® InternalBrace™ all-inside technique.

MATERIALS AND METHODS

The patient-reported functional outcomes and clinical outcomes were analyzed prospectively following the treatment of 324 unilateral ACL rupture cases with the FiberTape® InternalBrace™ Technique. Patient-reported outcome measures (KOOS scores, WOMAC scores, VAS score, and IKDC score) and clinical examinations like pre-operative and post-operative pivot shift, Lachman test, and range of motion (ROM) were conducted. These tests and examinations were recorded for each patient before surgery and at 3, 6, and 12 months after surgery. Secondary outcomes like re-rupture, infection, synovitis, or limited range of motion were noted. The mean follow-up period was 18±4.5 months (range: 12-24 months).

RESULTS

Out of a total of 324 cases, 37 cases (11.4%) could not be followed up. 158 patients (55.1%) were male and 129 were female (44.9%). Preoperative mean KOOS pain value, KOOS symptoms, KOOS ADLs, KOOS sport and recreation, and KOOS quality of life were 77.05, 78.69, 84, 21, 89.7, and 57, respectively. All KOOS subsections increased significantly at one-year to 98.37, 99.09, 98.95, 99.02, and 99.30 (p<0.0001), respectively. Mean preoperative WOMAC pain, WOMAC stiffness, and WOMAC function were 76.4, 65.2, and 74.1 and increased significantly at one-year to 94.5, 89.6, and 98.2 (p<0.0001), respectively. There was a significant decrease in VAS for pain from 2.93 before surgery to 0.12 (p<0.0001) at one year. The IKDC score significantly changed from a pre-treatment value of 50.9 to 96.2 (94.5-97.8) at a follow-up of one year. The Lysholm score at 12-months was significant at 95 (93.1-96.9), p<0.05. Post-operative Lachman test values decreased significantly, which meant decreased laxity, from 1.98 (1.89-2.07) pre-operative to 1.60 (1.57-1.62) p<0.05 at one-year post-operative. At one-year follow-up, 276 patients (96%) had fully recovered.

CONCLUSION

It was concluded that the FiberTape® InternalBrace™ technique for ACL reconstruction provides orthopedic surgeons with an effective alternative technique to conventional methods of surgery and also reduces the overall time to recovery for patients, thereby allowing them to return to sports faster.

LEVEL OF EVIDENCE

Level 4.

Stabilization and Gap Formation of Adjustable Versus Fixed Primary ACL Repair With Internal Brace: An in Vitro Full-Construct Biomechanical Cadaveric Study

Background

A knotless, tensionable primary anterior cruciate ligament (ACL) repair system preloaded with an internal brace has been released. Currently, there is no biomechanical data on the stabilization and gap formation behavior of the adjustable system when compared with fixed repairs in human ACL tissue.

Hypothesis

That knotless adjustable suture repair with an internal brace would provide overall higher construct stability and greater load share on the ACL with less gap formation compared with fixed repair.

Study Design

Controlled laboratory study.

Methods

Human cadaveric knees were utilized for internal braced ACL repair constructs (each group n = 16). Two fixed groups consisting of a single-cinch loop (SCL), cortical button (SCL group), and knotless suture-anchor (anchor group) were compared with an SCL-adjustable loop device (SCL-ALD) group. Testing was performed at 4 different peak loads (50, 150, 250, 350 N) over 4000 cycles at 0.75 Hz including suture repair preconditioning (10 cycles at 0.5 Hz) for SCL-ALD. Specimens were ultimately pulled to failure with a cut internal brace. The final loading situation of the construct and ACL repair with gap formation and ultimate strength were evaluated.

Results

Peak elongation at various peak loads showed a significantly higher (P < .001) stabilization of SCL-ALD when compared with both fixed groups. There was a significantly higher (P < .001) load share of SCL-ALD, especially at lower loads (48% of 50 N), and the gap formation remained restricted up to 250 N. With only a little load share on the fixed constructs (<6%) at lower loads (50, 150 N), gap formation in these groups started at a load of 150 N, leading to significantly higher gaps (P < .001). The ultimate failure load for SCL-ALD and anchor groups was significantly increased (P < .001) as compared with SCL. The stiffness of SCL-ALD (62.9 ± 10.6 N/mm) was significantly increased (P < .001).

Conclusion

Internal braced knotless adjustable fixation for ACL repair with preconditioning of the suture repaired ligament increased the overall stabilization with higher load share on the ACL and restricted gap formation (<0.5 mm up to 350 N) compared with fixed suture repair. All internal braced repairs restored stability according to native ACL function.

Clinical Relevance

Adjustable ACL repair improved the mechanical characteristics and reduced gap formation, but the overall clinical significance on healing remains unclear.

Biomechanical Comparison of 3 Adjustable-Loop Suspensory Devices for All-Inside ACL Reconstruction: A Time-Zero Full-Construct Model

Background

Little is known about the stability of adjustable-loop devices (ALDs) for anterior cruciate ligament (ACL) reconstruction (ACLR).

Purpose

To evaluate the stabilization behavior of 3 different types of ALDs for all-inside ACLR in a full-construct surgical technique-based manner.

Study Design

Controlled laboratory study.

Methods

The femoral and tibial devices of Ultrabutton (Smith & Nephew), Infinity (Conmed), and TightRope II (Arthrex) were applied to quadrupled bovine tendon grafts (n = 8 each) with tibial-sided traction applied (350 N) for graft tensioning in a simulated fully extended knee. Knotless femoral graft fixation was based on either a suture-locking device (SLD; Ultrabutton), button-locking device (BLD; Infinity), or dual-locking device (DLD; TightRope II). All constructs were progressively loaded (50 N/500 cycles) from 50 to 300 N for 3000 cycles (0.75 Hz), including complete unloading situations and pull to failure (50 mm/min). Construct elongation, stiffness, and ultimate load were analyzed.

Results

BLD showed significantly greater initial elongation (-2.69 ± 0.15 mm) than DLD (-3.19 ± 0.21 mm; P < .001) but behaved similarly to SLD (-2.93 ± 0.23 mm). While DLD and SLD had the smallest initial elongation at the same significance level, they behaved opposite to each other with gradually increasing peak loading. At the end of testing, DLD had the lowest (-0.64 ± 0.32 mm) and SLD the highest (3.41 ± 1.01 mm) total elongation (P < .003 for both). SLD displayed significantly higher dynamic elongation (6.34 ± 0.23 mm) than BLD (3.21 ± 0.61 mm) and DLD (2.56 ± 0.31 mm) (P < .001 for both). The failure load of BLD (865.0 ± 183.8 N) was significantly lower (P < .026) compared with SLD and DLD (>1000 N). The predominant failure mode was suture rupture and tibial bone breakage with button subsidence (SLD, n = 4). No significant difference in stiffness between constructs was found.

Conclusion

While DLD successfully restricted critical construct elongation, BLD partially and SLD completely exceeded the clinical failure threshold (>3 mm) of plastic elongation with loop lengthening during increasing cyclic peak loading with complete unloading. Higher failure loads of SLD and DLD implants (>1000 N) were achieved at similar construct stiffness to BLD.

Clinical Relevance

A detailed biomechanical understanding of the stabilization potential is pertinent to the continued evolution of ALDs to improve clinical outcomes.

Arthroscopic Anterior Cruciate Ligament Primary Repair With Synthetic Augmentation and Fixation With the Knotless Suture Anchor

An anterior cruciate ligament (ACL) tear is one of the most common ligament injuries in athletes. The arthroscopic ACL reconstruction procedure is the gold standard for treatment. However, the improvement in injury classification and suture materials has subsequently made arthroscopic ACL primary repair an alternative surgical treatment option. This Technical Note describes an arthroscopic ACL primary repair with synthetic augmentation made of several high-strength sutures and fixation with the knotless suture anchor. The reinforced synthetic material acts as a structural tie to support the ACL while it heals.

Reduced Incidence of Revision Anterior Cruciate Ligament Reconstruction With Internal Brace Augmentation

Background

Revision rates and outcome measures after anterior cruciate ligament reconstruction (ACLR) with suture tape as an internal brace is not well-documented because of the emerging nature of the technique.

Hypothesis

ACLR with internal bracing (IB) would lead to decreased revision ACLR compared with traditional ACLR while exhibiting comparable patient outcomes.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 200 patients were included in this study. Patients aged between 13 and 39 years at the time of surgery who underwent primary autograft ACLR with IB between 2010 and 2020 and were enrolled in our institution's registry with a minimum of 2-year follow-up were identified and matched 1 to 1 with a non-internal brace (no-IB) group based on concomitant procedures and patient characteristics. Pre- and postoperatively, patients completed the Knee injury and Osteoarthritis Outcome Score, Marx activity rating scale, Veterans RAND 12-Item Health Survey, and visual analog scale for pain. Knee laxity measurements via the KT-1000 arthrometer were included in the pre- and postoperative objective clinical assessments.

Results

A total of 100 IB patients were matched with 100 no-IB patients based primarily on concomitant procedures and secondarily on patient characteristics. The IB group underwent significantly fewer revision ACLRs (1% vs 8%; P = .017). Even though the no-IB group had a significantly longer mean final follow-up time (48.6 months [95% CI, 45.4-51.7] vs 33.4 months [95% CI, 30.3-36.5]; P < .001), the time elapsed from the original ACLR to the revision did not differ significantly between groups, and the mean ages for the IB and no-IB groups were comparable (19 vs 19.9 years). All postoperative patient-reported outcome scores between the 2 groups were comparable and significantly improved postoperatively except for the Marx score, which significantly decreased stepwise for both groups postoperatively. KT-1000 measurements significantly improved in both groups after surgery with the IB and no-IB cohorts yielding comparable results at the manual maximum pull (0.97 vs 0.65 mm).

Conclusion

ACLR with IB resulted in a significantly decreased risk of revision ACLRs while maintaining comparable patient-reported outcomes. Therefore, incorporating an internal brace into ACLR appears to be safe and effective within these study parameters.

Augmentation with Fibertape Leads to Biomechanically Superior but Similar Clinical Outcomes in ACL Surgeries: Systematic Review and Meta-analysis

Purpose

The current generation has witnessed significant progress in the field of knee arthroscopy. Suture tapes have gained immense popularity due to perceived improved biomechanical support to the graft while it heals. The purpose of the present systematic review is to analyze the biomechanical construct of suture tapes in ACL repairs and reconstructions along with clinical outcomes.

Methods

Cochrane Library, PubMed, and Embase were searched until December 2021. All Biomechanical Studies on animal or cadaver knees that compared construct characteristics of suture tape in ACL repair or reconstruction and clinical studies in English focusing on outcomes following suture tape augmentation in ACL repair or reconstruction were included. The quality of clinical studies using the Modified Coleman Methodology Score (MCMS).

Results

A total of 16 studies biomechanical and 23 clinical studies were included in qualitative synthesis, leaving nine biomechanical studies for final quantitative analyses. Suture tape revealed biomechanical superiority in terms of ultimate strength, stiffness, cyclic displacement, and elongation of graft, while comparing ACLR with internal brace to standard ACLR. No significant difference in retear rates was seen in clinical studies. Clinical score(IKDC score) was found similar in both augmented and non-augmented construct. Similar results were obtained in biomechanical studies.

Conclusion

The use of suture tape as a ligament augmentation in both ACL reconstruction and ACL repair offers more strength, less elongation or displacement, and is biomechanically stable and sound. There is a lack of data to comprehensively comment upon the clinical superiority of the use of internal augmentation. However, a meta-analysis of the retear rates and clinical outcome score revealed similar outcomes between suture tape augmented and nonaugmented groups.

Suture Augmentation Does Not Change Biomechanical Properties and Histological Remodeling of Tendon Graft in Anterior Cruciate Ligament Reconstruction: A Study in a Porcine Model

PURPOSE

To evaluate the initial safety of the combined use of ultra-high molecular weight polyethylene (UHMWPE) sutures for suture augmentation (SA) in a porcine ACL reconstruction model and examine whether the procedure can affect the anterior knee laxity and structural properties of the tendon graft itself, influence histological remodeling, and cause a foreign body-induced inflammation.

METHODS

Ten pigs were divided into SA and non-SA Groups to undergo ACL reconstruction using an autologous semitendinosus tendon with and without SA, respectively. At 12 weeks postoperatively, the tibial fixation of the grafted tendon and SA was removed, and the anterior knee laxity and structural characteristics of the grafted tendon were evaluated for mechanical testing. Histological evaluation, including the ligament tissue maturation index (LTMI) score and the presence or absence of foreign-body reaction, was evaluated.

RESULTS

There was no significant difference in anterior laxity between the two groups (SA Group, 1.19 ± 0.78 mm; non-SA Group, 1.08 ± 0.42 mm; P = 1). There were no significant differences in maximum load failure, yield strength, stiffness, elongation at failure, and the LTMI score between the two groups (P = 0.31, 1, 1, 1, and 0.24, respectively). All grafted tendons showed no foreign-body reactions.

CONCLUSION

Suture augmentation did not have significant effect on the anterior knee laxity and the structural properties of the grafted tendon, interfere with histological remodeling, or cause foreign body-induced reactions.

CLINICAL RELEVANCE

The results of our study may lay the foundation for further clinical studies to verify the usefulness of ACL reconstruction with SA.

Suture-tape augmentation of anterior cruciate ligament reconstruction: a prospective, randomised controlled trial (STACLR)

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction aims to restore anteroposterior and rotatory stability to the knee following ACL injury. This requires the graft to withstand the forces applied during the process of ligamentisation and the rehabilitative period. We hypothesise that the use of suture tape augmentation of single bundle ACL reconstruction (ACLR) will reduce residual knee laxity and improve patient-reported outcomes at 2-year follow-up. We will conduct a 1:1 parallel arm single-centre randomised controlled trial comparing suture tape augmented ACLR to standard ACLR technique.

METHODS

The study design will be a parallel arm 1:1 allocation ratio randomised controlled trial. Sixty-six patients aged 18 and over waitlisted for primary ACLR will be randomised. Patients requiring osteotomy and extra-articular tenodesis and who have had previous contralateral ACL rupture or repair of meniscal or cartilage pathology that modifies the post-operative rehabilitation will be excluded. The primary outcome measure will be the side-to-side difference in anterior tibial translation (measured on the GNRB arthrometer) at 24 months post-surgery. GNRB arthrometer measures will also be taken preoperatively, at 3 months and 12 months post-surgery. Secondary outcomes will include patient-reported outcome measures (PROMs) collected online, including quality of life, activity and readiness to return to sport, complication rates (return to theatre, graft failure and rates of sterile effusion), examination findings and return to sport outcomes. Participants will be seen preoperatively, at 6 weeks, 3 months, 12 months and 24 months post-surgery. Participants and those taking arthrometer measures will be blinded to allocation.

DISCUSSION

This will be the first randomised trial to investigate the effect of suture-tape augmentation of ACLR on either objective or subjective outcome measures. The use of suture-tape augmentation in ACLR has been associated with promising biomechanical and animal-level studies, exhibiting equivalent complication profiles to the standard technique, with initial non-comparative clinical studies establishing possible areas of advantage for the technique. The successful completion of this trial will allow for an improved understanding of the in situ validity of tape augmentation whilst potentially providing a further platform for surgical stabilisation of the ACL graft.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry ACTRN12621001162808. Universal Trial Number (UTN): U1111-1268-1487. Registered prospectively on 27 August 2021.

Clinical Research Progress of Internal Brace Ligament Augmentation Technique in Knee Ligament Injury Repair and Reconstruction: A Narrative Review

Knee ligament injuries are most common in sports injuries. In general, ligament repair or reconstruction is necessary to restore the stability of the knee joint and prevent secondary injuries. Despite advances in ligament repair and reconstruction techniques, a number of patients still experience re-rupture of the graft and suboptimal recovery of motor function. Since Dr. Mackay's introduction of the internal brace technique, there has been continuous research in recent years using the internal brace ligament augmentation technique for knee ligament repair or reconstruction, particularly in the repair or reconstruction of the anterior cruciate ligament. This technique focuses on increasing the strength of autologous or allograft tendon grafts through the use of braided ultra-high-molecular-weight polyethylene suture tapes to facilitate postoperative rehabilitation and avoid re-rupture or failure. The purpose of this review is to present detailed research progress in the internal brace ligament enhancement technique of knee ligament injury repair as well as the reconstruction from biomechanical and histological research and clinical studies and to comprehensively assess the value of the application of this technique.

Suture tape augmentation, a novel application of synthetic materials in anterior cruciate ligament reconstruction: A systematic review

Objective: Suture tape (ST) is a common synthetic material in the repairing surgery of soft tissue. Recently, ST augmentation (STA) technique has been described as a novel way to improve the mechanical property of grafts in the anterior cruciate ligament (ACL) reconstruction (ACLR). However, the clinical outcomes of ACLR using ST-augmented grafts have not been clarified. This systematic review aimed to summarize the specific technique of STA and evaluate the clinical outcomes after ACLR with STA. Methods: A electronic search of PubMed and Embase databases with a manual search of Google Scholar was performed to identify studies that reported the clinical outcomes of ACLR with STA. Each included study was abstracted regarding the study features, patient data, surgical information, and outcome measures. Results: Nine studies were included, representing 314 knees in 314 patients undergoing ACLR with STA. Technically, ST was fixed independently from grafts in six studies and along with grafts in two studies. Most studies applied an equal or slightly less tension on ST than ACL graft. Clinically, significant improvements were found in the Lysholm, IKDC, and KOOS scores after a mean follow-up of 16.7 months. Physical examinations of 220 patients showed significant restoration of knee stability at the final follow-up. 59 of 80 (73.8%) patients returned to preinjury sports level at a minimum 2 year follow-up. Six of 266 (2.3%) patients had a graft failure during the first 2 years postoperatively. The use of ST was significantly associated with better Tegner scores and a trend toward significantly higher rates of return to sport compared to standard ACLR. No significant difference was found in most subjective scores, knee laxity, and graft failures between ACLR with or without STA. Conclusion: ACLR with STA achieved overall favorable clinical outcomes. Patients using ST-augmented grafts were seemingly associated with better sports performance compared to standard ACLR. But ACLR with STA was not superior to ACLR alone in most functional scores, knee stability measures, and graft failure rates. A tension equal to or slightly less than the ACL graft should be carefully applied on ST during fixation to avoid stress shielding of the graft.

Comparison of Posterior Cruciate Ligament Reconstruction Using an All-Inside Technique With and Without Independent Suture Tape Reinforcement

Background

Biomechanical studies support the use of suture tape reinforcement for limiting graft elongation and increasing strength in knee ligament reconstructions.

Purpose

To compare posterior cruciate ligament (PCL) laxity, complication and reoperation rates, and patient-reported outcomes (PROs) after all-inside single-bundle PCL reconstruction (PCLR) with versus without independent suture tape reinforcement.

Study Design

Cohort study; Level of evidence, 3.

Methods

A retrospective cohort study of consecutive patients who underwent primary, all-inside allograft single-bundle PCLR with and without independent suture tape reinforcement at a single academic institution from 2012 to 2019. Medical records were reviewed for patient characteristics, additional injuries, and concomitant procedures. PRO scores (including the International Knee Documentation Committee [IKDC], Tegner activity scale, and Lysholm scores), bilateral comparison kneeling radiographs, and physical examination findings were collected at a minimum of 2 years postoperatively.

Results

Included were 50 patients: 19 with suture tape reinforcement (mean age 30.6 ± 2.9 years) and 31 without suture tape reinforcement (control group; mean age 26.2 ± 1.6 years). One PCLR graft in the suture tape group failed. Posterior drawer examination revealed grade 1+ laxity in 4 of 19 (21%) of the suture tape cohort versus 6 of 31 (19%) of the control cohort (P > .999). Bilateral kneeling radiographs showed similar side-to-side differences in laxity between the groups (suture tape vs control: mean, 1.9 ± 0.4 vs 2.6 ± 0.6 mm; P = .361). There were no statistically significant differences between the groups in postoperative IKDC (suture tape vs control: 79.3 vs 79.6; P = .779), Lysholm (87.5 vs 84.3; P = .828), or Tegner activity (5.6 vs 5.7; P = .562) scores.

Conclusion

All-inside single-bundle PCLR with and without independent suture tape reinforcement demonstrated low rates of graft failure, complications, and reoperations, with satisfactory PROs at a minimum 2-year follow-up. Radiographic posterior tibial translation was comparable between the 2 groups.

The Chinese knotting technique assist anatomical anterior cruciate ligament reconstruction for aggressive rehabilitation

Aggressive rehabilitation after anterior cruciate ligament (ACL) reconstruction may result in better clinical outcomes and fewer complications such as knee stiffness and weakness. We explored the effect of the Chinese knotting technique (CKT) for aggressive rehabilitation after ACL reconstruction. Ninety-one anatomical ACL reconstruction cases from 2016 to 2020 were retrospectively reviewed. All patients were operated by the same senior physician and his team. According to the reconstruction with or without CKT, the patients were divided into 2 groups. Both groups received aggressive rehabilitation. The follow-up time of 91 patients was more than 2 years. In total, 43 out of the 91 patients were in the CKT group, and 48 were in the routine group. The knee joint kinematics recorded by Opti_Knee revealed no significant difference among the CKT group, the routine group, and healthy adults at 3, 6, 12, and 24 months after the operation, respectively. The internal and external rotation angle and the anteroposterior displacement at 3 and 6 months after the operation in the CKT group were smaller than in the routine group and were similar to that of the healthy adults. There was no significant difference in flexion and extension angle, varus or valgus angle, proximal-distal displacement, or the internal or external displacement between the 2 groups. In addition, there was no significant difference in 6 degrees of freedom of the knee between the 2 groups at 12 and 24 months after the operation, respectively, which was similar to healthy adults. Compared to the routine group, the International Knee Documentation Committee scores were significantly higher in the CKT group at the 3, 6, and 12 months, respectively, but no difference was observed at 24 months (P = .749). The Lysholm score was significantly higher in the CKT group at the 3 and 6 months postoperatively, while there was no difference at 12 and 24 months, respectively. In short-term observation, the ACL reconstruction with CKT, which can sustain aggressive rehabilitation and prevent the loosening of ACL graft, can lead to better clinical outcomes and kinematics recovery of the knee compared to routine technique.

Suture Tape Augmentation Increases the Time-Zero Stiffness and Strength of Anterior Cruciate Ligament Grafts: A Cadaveric Study

Purpose

Methods

Results

Conclusion

Clinical Relevance

All-inside arthroscopic anterior cruciate ligament reconstruction with internal brace Ligament Augmentation using semitendinosus tendon autograft: A case series

Introduction and importance

Anterior Cruciate Ligament (ACL) reconstruction surgery has been proven to be closely related to the graft healing process, which can last up to 12 months after surgery. In recent years, through various biomechanical and clinical studies, Internal Brace Ligament Augmentation (IBLA) has been shown to protect the graft during these early postoperative stages and improve the outcome of ACL reconstruction. We present this case series of all-inside arthroscopic anterior cruciate ligament reconstruction with IBLA using semitendinosus tendon autografts, with the goal of evaluating postoperative clinical and patient-reported outcomes.

Case presentation

A total of 37 patients who underwent all-inside arthroscopic anterior cruciate ligament reconstruction with IBLA using only semitendinosus tendon autografts, were evaluated, in terms of patient reported outcome and clinical assessment, during the 3, 6 and 12 months post-operative follow-up. Results: The mean Lysholm Knee score at the final follow-up was 94,03 +- 3,65 with a difference of 34,59 +- 5,52 to the baseline level. International Knee Documentation Committee (IKDC) classification rated 30 cases of grade A and 7 cases of grade B. In terms of clinical tests and knee's range of motion, all patients have returned to normal, and no cases of re-rupture or other severe complications were found.

Clinical discussion

Early follow-up patient reported outcomes have provided good to great results for the 37 patients who underwent all-inside arthroscopic anterior cruciate ligament reconstruction with IBLA using semitendinosus tendon autografts and no cases of graft failure or other notable complication has been discovered. Clinical findings suggest improved knee's integrity and range of movement during the early stages, which may promote early rehabilitation, however future long-term comparative studies are needed.

Conclusion

IBLA with all-inside ACL reconstructions using only semitendinosus autograft has provided good to great results however, future long-term comparative studies are needed.

Suture Tape Augmentation of Anterior Cruciate Ligament Reconstruction Increases Biomechanical Stability: A Scoping Review of Biomechanical, Animal, and Clinical Studies

PURPOSE

To (1) assess the available literature reporting on suture tape augmentation in anterior cruciate ligament (ACL) reconstruction and (2) determine what evidence exists to support and oppose the technique in clinical practice.

METHODS

Five databases were systematically searched on November 24, 2021, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Technical, animal, biomechanical, and clinical studies were included. Quality appraisal was conducted according to study type. Data were extracted and reported in tabular and narrative form according to the study design.

RESULTS

In total, 1276 studies were appraised, with 22 studies including 6 biomechanical, 3 animal, 10 technical, and 3 clinical studies. Biomechanical studies reported tape-augmented grafts to withstand 12.2% to 73.0% greater load to failure and 17.0% to 60.2% reduced elongation compared with standard ACL reconstruction. Evidence of load sharing started at 200 N (7-mm graft) and 300 N (9-mm graft), with suture tape augments taking 31% and 20% of the final load (400 N), respectively, in one study. Among animal studies, no significant differences in complications, rates of ligamentization, histologic findings, or evidence of stress shielding were reported. Technical studies differed primarily in the method of fixation of the proximal end of the tape. Clinically, patient-reported outcome measures were mixed among significant and nonsignificant improvements in International Knee Documentation Committee scores and return to sport among tape-augmented groups, with no difference in complications.

CONCLUSIONS

Biomechanically, suture tape augmentation of ACL reconstruction increased the strength of the graft complex and reduced elongation, with early evidence of the "safety belt" effect with load-sharing properties at greater loads established. In animal studies, graft maturation and 4-zone bone healing, and equivalent rates of intra-articular complications were detected in ACL reconstruction with suture tape augmentation. In clinical studies, patient-reported outcomes were mixed between improved and equivalent outcomes with and without suture tape augmentation, whereas graft failure was not adequately powered to be assessed.

CLINICAL RELEVANCE

Suture tape augmentation of ACL reconstruction offers a low-cost method of improving initial biomechanical stability of the ACL graft. Animal and clinical data suggest the complication profile associated with synthetic grafts may not be apparent in tape augmentation. Independent suture tape augmentation may be considered with aims to increase the initial stability of the native ACL graft.