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

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.