Allograft Anterior Cruciate Ligament Reconstruction Utilizing Internal Brace Augmentation

[Research progress of suture augmentation in anterior cruciate ligament reconstruction]

Objective

To summarize the research progress of suture augmentation (SA) in anterior cruciate ligament (ACL) reconstruction.

Methods

A comprehensive review of recent literature about SA in ACL reconstruction at home and abroad was conducted. The efficacy of SA in ACL reconstruction was evaluated by examining the definition, biomechanics, and histological studies of SA, along with its clinical application status in ACL reconstruction.

Results

SA demonstrates significant advantages in enhancing the biomechanical stability of ACL grafts, reducing the risk of re-rupture, and accelerating postoperative recovery. Specifically, SA improves graft stiffness, ultimate failure strength, and cyclic stability, thereby diminishing the risk of early postoperative failure and joint instability. Histologically, it fosters remodeling and tendon-bone integration through early load-sharing mechanisms; however, stress shielding may interfere with natural remodeling processes, warranting further attention. Clinically, SA reduces graft failure rates and the need for revision surgeries, markedly improving knee joint stability and functional recovery in young patients. Nevertheless, its impact on graft maturation and potential complications remains controversial.

Conclusion

Despite the many advantages of SA in ACL reconstruction, future endeavors should focus on optimizing tensioning techniques, developing bioactive materials, and conducting large-scale randomized controlled trials to further elucidate its clinical value and scope of applicability, providing a more reliable solution for ACL reconstruction.

Assessment of the advantages and limitations of an innovative silk fibroin scaffold for the reconstruction of the anterior cruciate ligament with preclinical in vitro and in vivo evaluations

The gold standard treatment in anterior cruciate ligament (ACL) reconstruction involves autologous tissue transplantation, but this can have complications. Artificial grafts are an alternative, but the best option is debated. This study aimed to assess the biocompatibility and integration of a silk fibroin textile prosthesis (SF-TP) with peri-implant bone tissue and the native ACL. Twenty-six sheep underwent ACL reconstruction with SF-TP or autologous femoral fascia lata (FFL). Sheep were divided into two groups (3 and 6 months) and retrieved joints processed for histological, morphometrical and mechanical analysis. In vitro, SF-TP showed no cytotoxicity and good cell interaction up to 14 days. Histology revealed fibro-vascular tissue around SF-TP, with a progressive attempt of ligamentous-like tissue formation at 6 months. However, SF-TP group had higher joint damage scores. Micro-CT showed tunnel enlargement in SF-TP group, while FFL group had a decrease. SF-TP reconstructions had lower stiffness and strength (44 % and 64 % decrease) than those of autologous FFL reconstruction and often failed by pull-out from the bone tunnel due to tunnel enlargement. These results indicate poor osteointegration and graft motion with SF-TP, leading to joint damage/bone resorption and reduced mechanical competence. These results do not support the use of SF-TP for ACL reconstruction.

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.

Use of Internal Bracing in Multi-ligamentous Knee Injury Reconstruction: A Systematic Review

Background

Multi-ligament Knee Injuries (MLKI) are often caused by a high-energy impact resulting in dislocation of the knee joint. Given the higher degree of instability associated with these MLKIs, surgical fixation with adjunctive internal bracing and the use of suture augmentation have been proposed with the intention of better restoring knee stability and improving the long-term outcomes of surgery. This systematic review seeks to appraise the current literature in relation to the role of internal bracing in the management of MLKI.

Methods

All randomised control trials, observational studies, cohort studies, and cross-sectional studies containing patients with multi-ligamentous knee injuries managed with the use of internal bracing or suture tape augmentation were included in this review. The primary outcomes of interest were re-operation and failure rates, with secondary outcomes focussed on patient-reported outcome measures (PROMs) and examination findings of knee stability.

Results

282 studies were identified for screening, 13 of which were suitable for inclusion and five of these had injuries with Schenck grade III or above. Of the studies identified, failure rates ranged from 0 to 13.6%. Lysholm score was the most commonly utilised PROM tool with scores ranging from 61.8 to 95. Stiffness requiring MUA ± adhesiolysis was a common complication identified across studies.

Conclusions

The use of internal bracing in Multi-ligament Knee Injuries appears to be as effective as not using an internal bracing technique. The post-operative PROMs and relatively low failure rates reflect promising outcomes for the ongoing use of internal bracing in MLKI. However, further prospective studies directly comparing braced versus non-braced ligamentous repairs are required in order to definitively determine if the use of the internal brace does allow for increased joint stability and early rehabilitation.

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.

The effect of number of knots per throw, knot technique, and suture type on strength properties of suspensory fixation button surgical procedures

Background

Previous studies of the cortical suspensory button (CSB) implant have analyzed fixation strength as a function of suture type and surgical technique, but knot configuration remains an area of interest. This study investigates 4-strand knot configurations in CSB suspensory fixation, specifically comparing the use of 2 separate knots with a single knot. We hypothesize that using 2 knots on the distal side of the CSB with #2 suture will yield the strongest and stiffest suspensory fixation.

Methods

Two types of knot configurations were compared: a single knot with all 4 suture strands versus 2 independent knots with 2 suture strands each (1 knot from inner strands and 1 knot from outer strands). They were tested using #2 or 2-0 suture, and at distal (on top of the button) or proximal (underneath the button) knot positions. Mechanical testing on the Instron measured ultimate failure load, elongation at failure, and stiffness. Statistical analyses (Shapiro-Wilk, unpaired Student's t-tests, and Chi-square tests) assessed differences in strength, stiffness, elongation, and failure mode between knot configurations within each CSB construct combination.

Results

With #2 suture, 2 knots across the CSB resulted in higher load to failure compared to 1 knot in both proximal (467.00 N vs. 554.66 N, P = .026) and distal (395.18 N vs. 526.51 N, P < .001) locations. Furthermore, 2 knots provided higher stiffness than 1 knot in both proximal (53.24 N/mm vs. 67.89 N/mm, P < .001) and distal (47.08 N/mm vs. 56.73 N/mm, P = .041) knot locations. However, using 2-0 suture showed no significant differences in failure load and stiffness regardless of knot location.

Conclusion

Using #2 suture and tying 2 independent knots across the CSB increased load to failure and stiffness compared to using only 1 knot regardless of knot position. Thus, if using #2 suture, it is recommended to tie 2 knots to enhance construct strength. However, with 2-0 suture, the number of knots did not impact construct strength. Therefore, if using 2-0 suture, 1 knot can be used to save time. Knot position did not significantly affect the strength or stiffness of the CSB construct, emphasizing the importance of considering knot prominence and surgical approach for determining knot location.

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.

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.

All-Inside Anterior Cruciate Ligament Reconstruction Technique: Tips and Tricks

The all-inside anterior cruciate ligament reconstruction (ACLR) technique was developed to improve patient outcomes by reducing the procedure's invasiveness, minimizing complications and pain, and enabling faster postoperative recovery. This study presents a detailed description of the all-inside ACLR technique, which involves the use of quadrupled semitendinosus (ST) graft and suspension devices at both tibial and femoral sites, as well as valuable tips for avoiding complications that may arise during the procedure. The surgical procedure employs retrograde drills to create bony sockets for graft passage, which are then fixed with suspension devices at both the tibial and femoral sites. This technique has no specific restrictions and may be applied to all patients with anterior cruciate ligament (ACL) injuries. The literature reports the advantages, good clinical outcomes, and medium- to long-term graft survival achieved with the all-inside ACLR technique. However, the complications and disadvantages associated with the technique must be considered.

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.

Anatomical Double-Bundle Anterior Cruciate Ligament Reconstruction With Suture Augmentation

Ultra-high molecular weight polyethylene sutures are used for repair and reconstruction of extra-articular ligaments in the knee, elbow, and ankle joints. In recent years, the use of these sutures has become popular in a suture augmentation technique and has been applied for use in the reconstruction of the anterior cruciate ligament, which is an intra-articular ligament. Although several surgical techniques have been described in Technical Notes, all reports have been for single-bundle reconstruction, and none have applied the technique to double-bundle reconstruction. This Technical Note provides a detailed description of an anatomical double-bundle anterior cruciate ligament reconstruction combined with the suture augmentation technique.

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.

Good clinical scores, no evidence of excessive anterior tibial translation, a high return to sport rate and a low re-injury rate is observed following anterior cruciate ligament reconstruction using autologous hamstrings augmented with suture tape

INTRODUCTION

Augmented anterior cruciate ligament reconstruction (ACLR) techniques have been proposed to reduce the high reported re-injury rates and low rates of return to sport (RTS). This study reports clinical outcomes, RTS and re-injury rates in patients undergoing ACLR using autologous hamstrings augmented with suture tape.

MATERIALS AND METHODS

A total of 53 patients were prospectively recruited, undergoing ACLR using hamstrings with suture tape augmentation, combined with a structured rehabilitation programme. Outcomes were collected to 24 months, including patient-reported outcome measures (PROMs), KT-1000 measurements, peak isokinetic knee strength and a four hop test battery. Limb Symmetry Indices (LSIs) were calculated for performance measures, whilst RTS rates, re-tears and re-operations were presented.

RESULTS

There were no significant side-to-side differences in anterior tibial translation between the operated and non-operated knees at 6 months (p = 0.433), with no increase (p = 0.841) in side-to-side anterior tibial translation from 6 to 24 months. At 24 months, 98.0% of patients demonstrated normal (< 3 mm) or near normal (3-5 mm) side-to-side differences. LSIs for peak knee extensor torque (p < 0.0001) and the single (p = 0.001), triple (p = 0.001) and triple crossover (p < 0.0001) hop tests for distance significantly improved. All PROMs significantly improved (p < 0.0001), with 70.2% and 85.7% of patients actively participating in pivoting sports at 12 and 24 months, respectively. Three patients underwent secondary procedures for meniscal symptoms. One patient suffered an ACL re-tear (17 months), with no further ipsilateral or contralateral injuries.

CONCLUSION

ACLR with suture tape augmentation demonstrated no evidence of excessive anterior tibial translation, high-scoring PROMs, sound performance scores, a high rate of RTS and low re-injury rate.

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.

Biomechanical Effect of Differential Tensioning on Suture-Augmented Ulnar Collateral Ligament Reconstruction of the Elbow

BACKGROUND

Medial ulnar collateral ligament (mUCL) reconstructions are becoming increasingly prevalent among the overhand throwing population. Suture tape augmentation has the potential to provide biomechanical advantages over standard docking reconstruction. However, the optimal tensioning of the suture augmentation technique has not yet been evaluated.

PURPOSE

To compare the subfailure biomechanical performance and graft strain of a standard docking mUCL reconstruction to an mUCL reconstruction using suture tape augmentation tensioned with 1 mm or 3 mm of laxity.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 18 cadaveric elbows were dissected to the mUCL anterior band and biomechanically assessed via a valgus torque protocol to failure. Elbows were randomly assigned to be reconstructed via (1) a standard docking technique, (2) a suture-augmented reconstruction with 1-mm laxity, or (3) a suture-augmented reconstruction with 3-mm laxity. Reconstructed elbows were then subjected to the same loading protocol. Subfailure mechanical properties, failure mode, and mUCL/palmaris strain were assessed.

RESULTS

All reconstruction groups had decreased rotational stiffness, torque at 5° of angular rotation, and resilience compared with matched native controls. There were no differences in transition torque between groups. The failure mode of suture-augmented specimens was most often due to bone tunnel failure or reaching the maximum allowable angular displacement. In native controls or docking reconstructions, the primary failure mechanism was in the ligament or graft midsubstance. There were no significant differences in strain on the reconstructed or suture-augmented groups at any laxity compared with native controls.

CONCLUSION

Suture augmentation results in similar subfailure joint biomechanical properties as the standard docking reconstruction procedure at both laxity levels in a cadaveric model. There are improvements in the failure mode of suture-augmented specimens compared with standard docking. Graft strain may be modestly reduced in the 1-mm laxity group compared with other reconstruction groups.

CLINICAL RELEVANCE

Suture augmentation at both 1-mm and 3-mm laxity appears to offer similar advantages in subfailure biomechanics to standard docking reconstruction of the mUCL, with some improvements associated with failure mode. Strain data suggest a potential avoidance of graft stress shielding when tensioning the suture augmentation to 3-mm laxity, which is not as apparent with 1-mm laxity.

Clinical and arthroscopic outcomes of single-bundle anterior cruciate ligament reconstruction using autologous hamstrings augmented with ligament augmentation and reconstruction systems compared with four-strand hamstring tendon grafts alone

PURPOSE

To compare the clinical, radiological, and second-look arthroscopic outcomes in patients who underwent anterior cruciate ligament (ACL) reconstruction using a four-strand hamstring tendon graft (hamstring group) either without augmentation or with ligament augmentation and reconstruction system (LARS) augmentation (LARS augmentation group).

METHODS

From January 2018 to December 2019, patients who underwent ACL reconstruction were included. Patient-reported outcome measures (PROMs) were undertaken pre-operatively and at three, six, 12, and 24 months post-operatively. Arthroscopic evaluation was performed focusing on the morphology of the graft based on graft tension, graft tear, and synovial coverage.

RESULTS

A total of 178 consecutive patients received single-bundle ACL reconstruction, 89 patients in each group, and 20 patients were lost to follow-up in the first two years. At the three month follow-up, the LARS augmentation group had significantly higher Lysholm scores, IKDC scores, and KOS-ADLS scores than the hamstring group (P < 0.001). At the three, six and 12-month follow-ups, there were significantly higher Tegner scores and ACL-RSI scores in the LARS augmentation group than in the hamstring group (P < 0.05). At the three and six month follow-ups, the LARS augmentation group had significantly higher rates of return to sports and return to sports at their preinjury level (P < 0.05). There were no between-group differences in other outcomes, including arthroscopic outcomes, graft signal intensity, post-operative complications or rerupture rates.

CONCLUSIONS

Autologous hamstring augmented with the LARS augmentation technique provides good and realistic clinical and functional results during the early post-operative period with high levels of satisfaction of patients, including participation in sports and physical activity, and high rates of return to sports at the preinjury level, without any apparent complications compared with hamstring ACL reconstruction alone. No increases in complication, reinjury rates, or increased lateral laxity were observed at the 12-month or 24-month follow-up.

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.

Biomechanical Evaluation of Suture Tape Internal Brace Reinforcement of Soft Tissue Allografts for ACL Reconstruction Using a Porcine Model

Background:

Internal bracing of anterior cruciate ligament (ACL) surgery is a newer concept gaining popularity.

Purpose/Hypothesis:

To assess the biomechanical performance of soft tissue ACL reconstruction allografts reinforced with suture tape. It was hypothesized that load to failure would increase and cyclic displacement would decrease at time zero in the constructs reinforced with internal brace suture tape compared with those without suture tape augmentation.

Study Design:

Controlled laboratory study.

Methods:

We performed ACL reconstruction on porcine knees using bovine extensor tendon soft tissue allografts: 10 knees without (control) and 10 knees with (reinforced) suture tape reinforcement. An all-inside reconstruction technique was utilized with retrograde tunnel creation. An adjustable-loop device was used for femoral and tibial fixation of all grafts. The suture tape was placed through the tension loop in the femoral fixation construct and independently fixed in the tibia with an interference screw anchor. For each specimen, the authors recorded ultimate load, yield load, stiffness, cyclic displacement, and mode of failure. Outcomes between groups were compared using the Student t test.

Results:

There was a 33% decrease in mean cyclic displacement in the specimens with reinforced grafts (reinforced vs control: 3.9 ± 0.7 vs 5.8 ± 1.5 mm; P = .001). The reinforced grafts also had a 22% higher mean ultimate load (921 ± 180 vs 717 ± 122 N; P = .008) and a 25% higher mean yield load (808 ± 201 vs 602 ± 155 N; P = .020). There was no significant difference in stiffness between the reinforced versus nonreinforced grafts (136 ± 16 vs 132 ± 18 N/mm; P = .617). Three of the 10 control specimens failed at the graft, compared with 1 of 10 reinforced grafts. All other constructs in both groups failed at the tibial fixation site.

Conclusion:

Suture tape reinforcement of soft tissue grafts significantly decreased cyclic displacement while significantly increasing ultimate and yield loads without increasing graft construct stiffness during biomechanical testing at time zero in a porcine animal model.

Clinical Relevance:

The improved biomechanical performance of suture tape–reinforced graft constructs could allow patients to participate in earlier advancement of aggressive rehabilitation and potentially reduce failure rates as graft remodeling progresses.

Outcomes After Hamstring ACL Reconstruction With Suture Tape Reinforcement in Adolescent Athletes

Background:

Previous studies have suggested that suture tape-reinforced anterior cruciate ligament (ACL) grafts may have higher ultimate failure loads without stress-shielding. In patients at high risk for graft failure, such as adolescents, the addition of suture tape could have beneficial outcomes.

Hypothesis:

Suture tape reinforcement (STR) of ACL grafts in adolescent patients would lead to fewer graft ruptures during early recovery, without hindering subjective outcomes.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective review was performed on adolescent patients with a minimum 2-year follow-up after hamstring tendon autograft ACL reconstruction; enrolled were patients from both before (n = 40) and after (n = 40) a shift in surgical technique that added STR. Both the no-STR and the STR cohorts were contacted yearly to obtain patient-reported outcome data for visual analog scale (VAS; range, 0-10) for pain score, Single Assessment Numeric Evaluation, Lysholm score, Tegner activity score, patient satisfaction score (range, 0-100), and return to previous level of sport (yes/no). The cohorts were then matched based on follow-up duration, excluding those with follow-up of <2 years and >3 years to maintain consistency in duration of follow-up. Graft failure was defined as either graft rupture or recurrent instability symptoms, and failures occurring from index procedure to the 3-year mark were recorded for calculations of failure rate.

Results:

There were no differences between cohorts in mean age [STR, 15.7 years (range, 9.5-18.7 years); no STR, 14.9 years (range, 9.3-18.8 years)], follow-up duration, laterality, or graft size. While not statistically significant, 2 (5%) patients in the STR cohort experienced graft rupture compared with 7 (17.5%) patients in the no-STR cohort. The Tegner score was significantly higher in the STR cohort (P = .017); no between-group differences were seen on the other outcome scores. A subanalysis of the STR cohort comparing small-diameter grafts (<8 mm) with grafts ≥8 mm also demonstrated no difference in outcome measures, with 1 graft failure in each cohort.

Conclusion:

Study outcomes indicated that patients treated with ACL reconstruction and STR experienced a significant improvement in Tegner scores while at the same time maintaining the other subjective outcomes.

Outcomes after Multiligament Knee Injury Reconstruction using Novel Graft Constructs and Techniques

Clinical outcomes after reconstruction for multiligamentous knee injury (MLKI) can be consistently favorable. However, recent implants and technique advances may allow for improvement in outcomes. Our institution has developed novel graft constructs and techniques for reconstructions with preclinical data supporting clinical use. Our study purpose was to assess clinical outcomes after reconstruction for MKLI using our constructs and techniques. Overall success rate, failure/revision rates, return to work (RTW)/return to sports (RTS) rates, and complications were evaluated testing the hypothesis that novel methods would be associated with clinical benefits with respect to applications and outcomes compared with historical results. We reviewed a single-surgeon, longitudinal database of 42 patients who underwent multiligament reconstruction at our institution using these techniques for at least two-ligament injuries. Visual analogue scale (VAS) pain score and PROMIS (patient-reported outcomes measurement information system) were collected preoperatively and postoperatively at a minimum 1-year follow-up. Among these patients, 33 patients (mean age of 28.9 years, mean body mass index (BMI) of 33.2 kg/m², mean follow-up of 14.2 months) were included for outcomes analyses. With the definition of success as having a VAS score of less than or equal to 2 without revision/salvage surgery due to recurrent/residual instability or arthritis, overall success rate was 88% (29/33). The mean VAS scores improved from 5 ± 2 to 2 ± 2. The mean preoperative PROMIS mental health score was 36.2 ± 7, general health was 33.5 ± 6, pain was 62.7 ± 8, and physical function score was 29.4 ± 3. At the final follow-up, PROMIS MH was 50.2 ± 10, GH was 44.4 ± 9, pain was 54.3 ± 9, and PF was 42.6 ± 8.4. Return to work rate was 94% (31/33), and 52% (17/33) of patients were able to RTS at any level. Our results demonstrated excellent clinical outcomes associated with a primary success rate of 88% and RTW rate of 94%. Intraoperative complications occurred in 9.5% of cases and revision and failure rates were 9% and 3%, respectively. Our initial results suggest that multiligament reconstructions using novel graft constructs and techniques are safe and effective and can be considered an appropriate option for reconstruction of the full clinical spectrum of MLKIs.

Development and Assessment of Novel Multiligament Knee Injury Reconstruction Graft Constructs and Techniques

Multiligament knee injury (MLKI) typically requires surgical reconstruction to achieve the optimal outcomes for patients. Revision and failure rates after surgical reconstruction for MLKI can be as high as 40%, suggesting the need for improvements in graft constructs and implantation techniques. This study assessed novel graft constructs and surgical implantation and fixation techniques for anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), posterior medial corner (PMC), and posterior lateral corner (PLC) reconstruction. Study objectives were (1) to describe each construct and technique in detail, and (2) to optimize MLKI reconstruction surgical techniques using these constructs so as to consistently implant grafts in correct anatomical locations while preserving bone stock and minimizing overlap. Cadaveric knees (n = 3) were instrumented to perform arthroscopic-assisted and open surgical creation of sockets and tunnels for all components of MLKI reconstruction using our novel techniques. Sockets and tunnels with potential for overlap were identified and assessed to measure the minimum distances between them using gross, computed tomographic, and finite element analysis-based measurements. Percentage of bone volume spared for each knee was also calculated. Femoral PLC-lateral collateral ligament and femoral PMC sockets, as well as tibial PCL and tibial PMC posterior oblique ligament sockets, were at high risk for overlap. Femoral ACL and femoral PLC lateral collateral ligament sockets and tibial popliteal tendon and tibial posterior oblique ligament sockets were at moderate risk for overlap. However, with careful planning based on awareness of at-risk MLKI graft combinations in conjunction with protection of the socket/tunnel and trajectory adjustment using fluoroscopic guidance, the novel constructs and techniques allow for consistent surgical reconstruction of all major ligaments in MLKIs such that socket and tunnel overlap can be consistently avoided. As such, the potential advantages of the constructs, including improved graft-to-bone integration, capabilities for sequential tensioning of the graft, and bone sparing effects, can be implemented.

Graft position at the femoral condyle affects knee mobility after posterior cruciate ligament replacement

BACKGROUND

In some cases posterior cruciate ligament (PCL) tears require surgical reconstruction. As the femoral footprint of the ligament is quite large, an ideal graft fixation position on the medial notch wall has not yet been identified. The aim of this study was to compare three different graft fixation positions within the anatomical footprint of the PCL and test it for posterior tibial translation at different knee flexion angles.

METHODS

In six human knee specimens a drawer test was simulated on a material testing machine by applying load on the tibia. At three different knee flexion angles (0°, 45°, 90°) knee mobility was examined with respect to tibial posterior translation and stiffness for the following conditions: intact ligaments, detached PCL, three different graft fixation positions on the femoral condyle.

RESULTS

Replacement of the PCL within its femoral footprint restored knee stability in terms of tibial posterior translation. Low graft position showed comparable drawer displacements to the intact condition for all knee flexion angles (p > 0.344). A higher graft position excessively reduced the posterior translation (p < 0.047) and resulted in a restricted knee mobility and a stiffer joint.

CONCLUSIONS

Graft fixation positions on the femoral condyle play a crucial role in post-operative knee mobility and joint functionality after PCL replacement. Even though all graft fixation positions were placed within the femoral footprint of a native PCL, only the lower position on the medial notch wall showed comparable posterior tibial translation to an intact PCL.

[Research progress of internal tension relieving technique in assisting anterior cruciate ligament reconstruction]

OBJECTIVE

To review the research progress of internal tension relieving technique in assisting anterior cruciate ligament (ACL) reconstruction with tendon grafts.

METHODS

The in vivo and in vitro biomechanical tests, animal experiments, and clinical studies on the use of internal tensioning relieving technique assisted ACL reconstruction in recent years were extensively reviewed, the impact of this technology on the biomechanics, histological changes of grafts, and the clinical effectiveness were analyzed and summarized.

RESULTS

The internal tensioning relieving technique based on non-absorbable high-strength sutures can reduce the risk of relaxation and rupture by enhancing the biomechanical strength of tendon grafts in vitro and in vivo, it shows good biocompatibility and support for the ligamentation of the tendon grafts and the establishment of the direct tendon-bone interface in terms of histology. This technique improves postoperative initial joint stability, range of motion, and functional scores in clinical practic, when combining with the enhanced recovery after surgery can effectively promote patients to return to pre-injury exercise level without serious complications.

CONCLUSION

The preliminary research results have confirmed the efficacy and safety of the internal tension relieving technique on assisting ACL reconstruction, then showes some degree of significance and prospect, but more research is needed to further optimize tension-relieving devices and related surgical techniques, and clarify the specific effects of this technique on graft's structure remodeling, biomechanical function, and long-term clinical results.

Biomechanical Comparison of Modified Adams-Berger and DX technique in DRUJ Reconstruction

Background  Adams-Berger ligamentoplasty is a widely accepted reconstruction for unrepairable triangular fibrocartilage complex (TFCC) injuries with instability. Failure of the reconstruction and recurrent instability is still a clinical problem. Internal brace augmentation of tendon grafts is gaining more popularity, but use in the distal radioulnar joint (DRUJ) is not yet published. Questions/Purposes  The purpose of this study was to compare a novel anatomical DRUJ reconstruction with a modified Adams-Berger reconstruction to answer which technique stabilize better the DRUJ and which has enough stabilizing effect to allow early mobilization. Methods  Nine matched pairs of cadaveric upper extremities were used. The dorsopalmar translations in the DRUJ that occurred with 50 N load were measured before and after detachment of the TFCC from the ulna and after ligament reconstruction with either modified Adams-Berger procedure or DX Swivelock technique. Internal brace augmented palmaris longus tendon grafts were used in all reconstruction. Results  In the Adams-Berger group, the injured and the reconstructed displacements were significantly higher than the native, while in the DX group both the native and the reconstructed displacements were significantly lower than the injured. The mean (standard deviation) change of translations was 0.46 (1.94) mm after Adams-Berger and 2.51 (1.31) mm after DX reconstruction, implying significant better stabilizing effect of the latter. Conclusions  DX Swivelock reconstruction showed better time zero stabilizing effect compared with Adams-Berger procedure, regaining almost normal stability of the DRUJ.

All-Inside Anterior Cruciate Ligament Reconstruction with Suture Tape Augmentation: Button Tie-Over Technique (BTOT)

The anterior cruciate ligament (ACL) is the most common ligamentous knee injury in pivoting sports. There are multiple techniques described for ACL reconstruction; however, still there is an ongoing debate regarding the optimal technique with minimal residual laxity and least risk of rerupture. All-inside ACL reconstruction with suture tape augmentation (InternalBrace) is a newly developed method of ACL reconstruction to help address these issues. Suture tape protects the graft during ligamentization process. The aim of this article is to describe a modified all-inside ACL reconstruction technique with suture tape augmentation in which the internal brace is tied distally over the distal TightRope button without an extra method of fixation.

Suture Tape Augmentation Improves the Biomechanical Performance of Bone-Patellar Tendon-Bone Grafts Used for Anterior Cruciate Ligament Reconstruction

PURPOSE

The purpose of this study was to investigate the time-zero biomechanical properties (stiffness, displacement, and load at failure) of bone-patellar tendon-bone (BTB) grafts used for anterior cruciate ligament (ACL) reconstruction with and without suture tape augmentation as a means to determine the potential clinical benefit of this technique.

METHODS

Eight juvenile porcine knees underwent ACL reconstruction with a human cadaveric BTB graft (control). These were compared to 8 juvenile porcine knees that underwent ACL reconstruction with a BTB graft augmented with suture tape. All knees underwent biomechanical testing utilizing a dynamic tensile testing machine. Cyclic loading between 50-250N was performed for 500 cycles at 1 Hz to simulate in vivo ACL loads during the early rehabilitation phase. The grafts were displaced during load-at-failure tensile testing at 20 mm/min. Differences in graft displacement, stiffness, and load at failure for the control and suture tape augmented groups were compared with the Student t-test with a significance level of P < .05.

RESULTS

There was no difference in graft displacement between the 2 groups. A 104% higher postcyclic stiffness was noted in the augmented group compared to the controls (augmentation: 261 ± 76 N/mm versus control 128 ± 28 N/mm, P = .002). The mean ultimate load at failure was 57% higher in the augmented group compared to controls (744 ± 219 N vs postcyclic 473 ± 169 N, respectively [P = .015]). There was no difference in mode of failure between the control knees and those augmented with suture tape, with approximately half failing from pull off of the tendon from the bone plug and half with pull out of the bone plug from the tunnel.

CONCLUSION

Independent suture tape augmentation of a BTB ACL reconstruction grafts was associated with a 104% increase in graft stiffness and a 57% increase in load at failure compared to nonaugmented BTB grafts.

CLINICAL RELEVANCE

In vivo suture tape augmentation of a BTB ACL reconstruction increases graft construct strength and stiffness, which may reduce graft failure in the clinical setting.

Posterior Cruciate Ligament Reconstruction With Internal Brace Augmentation Reduces Posterior Tibial Translation Under Cyclic Loading

The goal of this study was to evaluate the stiffness and resistance to elongation of an internal bracing (IB) construct in posterior cruciate ligament reconstruction (PCLR). The authors hypothesized that augmentation with an internal brace would increase construct stiffness and decrease posterior tibial translation during cyclic loading in a fresh frozen cadaveric model. Ten cadaver knees underwent PCL reconstruction with (PCLR+IB) and without (PCLR) augmentation with an internal brace and were compared with an intact PCL state. Knees were subjected to cyclic posterior drawer loading at 45 N, 90 N, and 134 N. The PCLR+IB showed significantly less tibial translation with posterior drawer loading compared with the PCLR. Posterior tibial translation measured 8.83 mm for the PCLR vs 6.59 mm for the PCLR+IB (P=.05) at 45 N posterior load. This difference remained significant at higher loads, with posterior translation of 10.84 mm and 8.44 mm for PCLR and PCLR+IB, respectively, at 90 N (P=.035) and posterior translation of 12.80 mm and 10.23 mm for PCLR and PCLR+IB, respectively, at 134 N (P=.023). No significant differences were found in overall construct stiffness between groups. These data suggest a checkrein mechanism of action for the internal brace in this construct, rather than a load-sharing mechanism. Importantly, the PCLR+IB technique did not constrain posterior translation more than the intact, physiologic state. Clinical studies are warranted to determine whether these ex vivo biomechanical benefits will translate to improved outcomes. [Orthopedics. 2021;44(4):235-240.].

Preparation and biological characteristics of a bovine acellular tendon fiber material

Acellular tendon matrix is an ideal substitute for constructing tissue engineering ligaments, but using detergents causes damage to collagen and fibrin during the process of decellularization. In this study, fresh tendons were lyophilized and separated into fresh tendon fiber (FTF) bundles, and then the cellular components in FTF were removed to prepare acellular tendon fiber (ATF) without adding chemical detergent. H&E staining and DAPI fluorescence microscopy showed no nucleus and DNA residue. Compared with FTFs, the DNA content of ATFs was significantly lower without the collagen content change before and after decellularization. The microstructure of collagen fibrils in ATFs was intact under scanning electron microscopy (SEM), and the maximum tensile load and elastic modulus between FTFs and ATFs were not statistically different. The ATF bundles were cultured with SD rat tenocytes for 72 hr and cells attachment to fiber surfaces were observed under SEM. ATF bundles were then implanted into paraspinal muscles, and histological analysis showed fibroblast-like cells within the ATFs and was similar to the control group (fresh tendon autograft) in morphology. H&E staining showed that the number of lymphocytes and plasma cells in ATF was less than that in fresh tendon autograft. ATF bundles were twisted into linear fiber materials by hand, of which the maximum breaking strength was similar to silk with same diameter. These findings demonstrated that ATFs retain their original fibril structure and mechanical properties after decellularization by trypsin and pancreatic deoxyribonuclease without detergent. Lyophilized ATFs linear fiber material provides the possibility of preparing personalized ligament and other tissue engineering scaffolds.

Self-Tensioning Feature of Knotless Suture Anchor Provides Reproducible Knotless Fixation Independent of Initial Tension

Background:

Anterior cruciate ligament (ACL) reconstruction with suture tape reinforcement has been shown to biomechanically reduce elongation and increase ultimate strength. However, the amount and consistency of the achieved tension after primary fixation using knotless suture anchors remains unclear.

Purpose:

To determine whether initial tensioning of suture tape before fixation with a knotless suture anchor significantly affects final tension of the suture tape.

Study Design:

Controlled laboratory study.

Methods:

We secured 15 pairs of Sawbones blocks with predrilled tunnels to a tensile testing machine. Suture tape was inserted through a suspensory fixation button on the representative femoral block and threaded top-down through the base of the tibial block over an attachable button system. The suture tape was attached with a knotless suture anchor in a predrilled and tapped hole on the tibial block under the following pretensioning conditions: (1) slight tension of 5 N, (2) no tension, and (3) initial slack. The suture anchor was inserted as the load-time data were recorded. After initial block testing, a porcine model of 24 tibias was used to test the same pretensioning conditions. The initial loads during anchor insertion and screw-in were measured, as well as final tension.

Results:

During block testing, no difference in final tensioning was found when comparing the slight-tension, no-tension, and slack groups (42.3 ± 5.3, 37.7 ± 6.4, and 40.2 ± 7.0 N, respectively; P = .528). Similar to block testing, no difference in final tensioning was found when comparing the slight-tension, no-tension, and slack groups using the porcine model (43.64 ± 6.69, 48.09 ± 13.93, and 44.52 ± 6.84 N, respectively; P = .633).

Conclusion:

The final tension of the suture tape construct appears to be reproducible and consistent, independent of the initial tension introduced with suture anchor placement within the tested parameters.

Clinical Relevance:

The results of the current study can help optimize the placement technique of independent suture tape reinforcement for ACL reconstruction, which is a promising strategy to help prevent ACL rerupture, particularly in the early phases of postoperative rehabilitation.

Anatomic Double-Bundle ACL Reconstruction With Extra-articular Anterolateral Ligament Reconstruction and Internal Brace

Anterior cruciate ligament reconstruction (ACLR) with additional procedures could be necessary for patients with increased preoperative pivot shift. Double-bundle (DB) ACLR provides more footprint coverage and recreates the 2 functional anteromedial (AM) and posterolateral (PL) bundles, which are believed to give better joint function and stability than single-bundle (SB) ACLR. Internal brace augmentation with suture tape is proposed along with tendon graft in ACLR to protect the newly reconstructed ligament during rehabilitation. Additional reconstruction with anterolateral ligament (ALL) during ACLR has shown significant reduction in the level of persistent pivot shift. In Technical Note we present a modified surgical technique of combined anatomic DB ACLR and ALLR with hamstring autograft and internal brace, using button suspensory fixation device and aperture screws. The objective of this technique is to decrease residual anterior and rotational instability after ACLR and ALLR.

[Arthroscopic reinforced reconstruction of anterior cruciate ligament with autologous hamstring tendon and anchor suture band]

OBJECTIVE

To investigate the effectiveness of arthroscopic reinforced reconstruction of anterior cruciate ligament (ACL) with autologous hamstring tendon combined with anchor suture band.

METHODS

Between February 2016 and March 2018, 60 patients who were to be treated with arthroscopic ACL reconstruction and met the selection criteria were selected in the study. Among them, 30 cases were reconstructed with autologous hamstring tendon combined with anchor suture band (trial group), and 30 cases were reconstructed with simple autologous hamstring tendon (control group). There was no significant difference in gender, age, disease duration, cause of injury, injury side, and preoperative Lysholm score, Tegner score, and International Knee Documentation Committee (IKDC) score between the two groups ( P>0.05). After reconstruction, the patients in the trial group were allowed to start knee flexion and extension activities early without wearing an adjustable brace, while the patients in the control group were required to wear an adjustable brace for 12 weeks. The knee joint function (Lysholm score, Tegner score, IKDC score) and stability (Lachman test and pivot shift test) were compared between the two groups after operation.

RESULTS

There was no significant difference in graft diameter between the two groups ( t=1.061, P=0.115). Compared with the control group, the operation time of the trial group was significantly different ( t=4.924, P=0.000). All incisions healed primarily. In the control group, the intramuscular venous thrombosis occurred in 2 cases after operation. Both groups were followed up 18 months. The Lysholm score, Tegner score, and IKDC score of the two groups at each time point after operation were significantly higher than those before operation ( P<0.05); the above scores in the trial group were significantly higher than those in the control group at 3, 6, and 9 months after operation ( P<0.05); there was no significant difference between the two groups at 18 months after operation ( P>0.05). There was no significant difference in Lachman test results between the two groups at each time point after operation ( P>0.05). There was a significant difference in pivot shift test results at 6 months after operation between the two groups ( P<0.05); but there was no significant difference at other time points ( P>0.05).

CONCLUSION

The effectiveness of ACL reinforcedreconstruction with autologous hamstring tendon combined with anchor suture band is satisfactory. Compared with using autologous hamstring tendon alone, it has better initial strength and joint stability, and is more conducive to early postoperative functional exercise and functional recovery of knee joint.

A Technique for Anterior Cruciate Ligament Reconstruction in the Setting of Unicompartmental Knee Arthroplasty

Unicompartmental knee arthroplasty (UKA) is becoming a more prevalent treatment for medial-compartment arthritis. Traditionally, a competent anterior cruciate ligament (ACL) is required to achieve satisfactory results. This leads to the question of treatment for medial-compartment arthritis in the setting of an incompetent ACL. A treatment option for this subset of patients is concurrent UKA and ACL reconstruction; however, this technique addresses the cohort of patients with a previously stable UKA who sustain an injury to the ACL, leading to symptomatic instability. The purpose of this article is to detail a technique for ACL reconstruction in the setting of a previous UKA.

The Use of Suture Augmentation for Graft Protection in ACL Reconstruction: A Biomechanical Study in Porcine Knees

Purpose

To biomechanically evaluate the use of the suture augmentation construct at time 0 of ACL reconstruction.

Methods

Eighty porcine knees underwent ACL reconstruction using 2 techniques for graft fixation: a single suspensory construct (SSC), performed with a femoral button and tibial interference screw; and a double suspensory construct (DSC), with a femoral and tibial button. Each fixation technique was performed on 40 porcine knees divided into 4 subgroups. The first group had a nonaugmented ACL reconstruction, the second group had an ACL reconstruction with suture augmentation, and the third and fourth groups were the same as the first and second groups, with the graft resected 80% to simulate graft weakening. Ultimate load, yield load, stiffness, cyclic displacement values, and mode of failure were recorded for each graft.

Results

In a weakened graft model with 80% graft resection, there was a significant increase in ultimate strength (P < .001), yield strength (P < .001), and cyclic displacement (P < .001) with suture augmentation. There was no significant increase in stiffness with suture augmentation with either construct (P = .278). In the setting of an intact graft, there were no differences in either SSC or DCS groups with or without suture augmentation.

Conclusions

The addition of a suture to ACL reconstruction techniques resulted in minimal changes in baseline biomechanical characteristics while improving ultimate load, yield load, and cyclic displacement in a weakened graft model.

Clinical Relevance

Suture augmentation of ACL reconstruction may confer improved integrity of the graft and is worth consideration and future clinical study.

Patellar Bone-Tendon-Bone Autografts versus Quadriceps Tendon Allograft with Synthetic Augmentation in a Canine Model

Patellar bone-tendon-bone (pBTB) autografts are often considered the "gold standard" for complete anterior cruciate ligament (ACL) reconstruction and are also associated with significant complications and early-onset knee osteoarthritis (OA). A novel quadriceps tendon allograft with synthetic augmentation, or "internal brace" (QTIB), has been reported to have potential advantages for ACL reconstruction based on animal model data. In this preclinical canine comparison study, we hypothesized that QTIB allograft compared with pBTB autograft would provide superior durability for knee stability, function, and prevention of OA. Under approval from our Institutional Animal Care and Use Committee, adult purpose-bred research hounds (n = 10) underwent arthroscopic complete transection of the ACL followed by either an arthroscopic-assisted all-inside ACL reconstruction using the QTIB allograft (n = 5) or pBTB autograft (n = 5). Contralateral knees were used as nonoperated controls (n = 10). Radiographic and arthroscopic assessments were performed at 2 and 6 months, respectively, after surgery. Anterior drawer, internal rotation, lameness, kinetics, pain, effusion, and comfortable range of knee motion were measured at 2, 3, and 6 months. Biomechanical and histologic assessments were performed at 6 months. All reconstructed knees were stable and had intact ACL grafts 6 months after surgery. At 6 months, QTIB reconstructed knees had significantly less lameness, lower pain, less effusion, and increased range of motion when compared with BTB knees (p < 0.05). BTB knees had significantly higher radiographic OA scores than QTIB knees at 6 months (p < 0.05). Superior outcomes associated with QTIB allograft may be due to the lack of donor site morbidity, the use of a robust tendon graft, and/or protection of the graft from the synthetic augmentation. Robust tendon grafts combined with a synthetic internal brace and platelet-rich plasma (PRP) may allow for more rapid and robust tendon-bone healing and graft "ligamentization," which protects the graft from early failure and rapid OA development that can plague commonly-used allografts.

Independent Suture Tape Internal Brace Reinforcement of Bone-Patellar Tendon-Bone Allografts: Biomechanical Assessment in a Full-ACL Reconstruction Laboratory Model

Internal bracing for anterior cruciate ligament (ACL) surgery is a relatively new concept. The purpose of this study was to evaluate the effects of an "independent" button-fixed internal brace on the biomechanical properties of ACL reconstruction in a full-construct experimental model. Three groups (n = 10 each) were tested in a full-construct porcine-bone model with human bone-patellar tendon-bone allografts using different reconstruction techniques: interference screw fixation on femur and tibia (S-S group), adjustable-loop device (ALD) fixation on the femur with tibial interference screw without suture tape (ALD-S group), and with internal brace (ALD-S-IB group). Measured outcomes included cyclic displacement, stiffness, and ultimate load to failure. The ALD-S-IB group (2.9 ± 0.8 mm) displaced significantly less than the ALD-S (4.2 ± 0.9 mm; p = 0.015) and S-S group (4.3 ± 1.1 mm; p = 0.017). No significant difference was found between the ALD-S and the S-S group. Construct stiffness was significantly higher for the ALD-S-IB group (156 ± 23 N/mm) and the ALD-S group (122 ± 28 N/mm) than for the S-S group (104 ± 40 N/mm; p = 0.003 and p = 0.0042), but there was no significant difference between both ALD groups. Similarly, ultimate loads in the ALD-S-IB (758 ± 128 N) and the ALD-S groups (628 ± 223 N) were significantly greater than in the S-S group (416 ± 167 N; p < 0.001 and p = 0.025), but there was no significant difference between ALD groups. Adding an internal brace reinforcement to an ALD in a full-construct experimental model significantly decreased cyclic displacement by 31% without increasing construct stiffness or ultimate load significantly. These results indicate that suture tape internal bracing of bone-patellar tendon-bone allograft ACL reconstruction decreases cyclic displacement during experimental testing, which has clinical implications regarding initial construct stability.

Return to Play in Athletes After Thumb Ulnar Collateral Ligament Repair With Suture Tape Augmentation

Background:

Thumb ulnar collateral ligament (UCL) tears are common in competitive athletes. These tears often occur as a result of a radially directed force on an extended thumb. To date, no literature exists on the use of suture tape augmentation for repair of the thumb UCL in a competitive athlete cohort.

Hypothesis:

Using suture tape augmentation for the thumb UCL will allow for a safe and expedient return to play in competitive athletes.

Study Design:

Case series; Level of evidence, 4.

Methods:

A retrospective chart review was completed to identify all patients who underwent operative primary thumb UCL repair between 2014 and 2018. All procedures were performed at a single institution by the senior author. Inclusion criteria were acute complete tears of the thumb metacarpophalangeal joint UCL, treated with primary repair via suture tape augmentation in competitive high school, collegiate, or professional athletes. Exclusion criteria included recreational athletes, patients who underwent reconstruction (rather than repair), and patients with insufficient follow-up to establish return to play. Charts of patients identified through the retrospective review were further evaluated to determine patient- and injury-related variables. Return to play was defined as return to game competition and stratified as to whether this was at the same level of competition or any level of competition.

Results:

A total of 18 thumbs in 17 competitive high school, collegiate, and professional athletes were included in this study. One of the professional basketball players sustained injury to both thumbs approximately 10 months apart. The study group comprised 4 collegiate baseball players, 6 professional baseball players, 3 professional basketball players, 1 professional hockey player, 1 amateur-level hockey player, 1 high school basketball player, and 1 high school volleyball player. Mean follow-up was 27.9 months, and no complications were noted. Athletes who sustained an in-season injury (n = 13; 72.2%) returned to play at any level at a mean ± SD of 30.9 ± 10.1 days and at the same level at 36.3 ± 11.2 days. Athletes who sustained an out-of-season injury (n = 5; 27.8%) returned to play at any level at 101.4 ± 86.6 days and at the same level at 114.6 ± 87.0 days.

Conclusion:

The findings presented here offer evidence for return to play in competitive high school, collegiate, and professional athletes with a thumb UCL tear treated with repair and suture tape augmentation. All athletes returned to the same level of play. Those attempting to return in-season returned to the same level of play at a mean of just under 5 weeks. Augmenting the repair with anchored suture may prevent prolonged immobilization, expedite thumb motion, and improve postoperative recovery.

Biomechanical evaluation of PCL reconstruction with suture augmentation

PURPOSE

The purpose of this study was to compare kinematics and patellofemoral contact pressures of all inside and transtibial single bundle PCL reconstructions and determine if suture augmentation further improves the biomechanics of either technique.

METHODS

Cadaveric knees were tested with a posterior drawer force, and varus, valgus, internal and external moments at 30, 60, 90, and 120° of flexion. Displacement, rotation, and patellofemoral contact pressures were compared between: Intact, PCL-deficient, All-Inside PCL reconstruction with (AI-SA) and without (AI) suture augmentation, and transtibial PCL reconstruction with (TT-SA) and without (TT) suture augmentation.

RESULTS

Sectioning the PCL increased posterior tibial translation (PTT) from intact at 60° to 120° of flexion, p < 0.001. AI PCL reconstruction improved stability from the deficient-state but had greater PTT than intact at 90° of flexion, p < 0.05. Adding suture augmentation to the AI reconstruction further reduced PTT to levels that were not statistically different from intact at all flexion angles. TT reconstructed knees had greater PTT than intact knees at 60, 90, and 120° of flexion, p < 0.01. Adding suture augmentation (TT-SA) improved posterior stability to PTT levels that were not statistically different from intact knees at 30, 60, and 120° of flexion. Patellofemoral pressures were highest in PCL-deficient knees at increased angles of flexion and were reduced after reconstruction, but this was not significant.

CONCLUSION

In this time-zero study, both the all-inside and transtibial single bundle PCL reconstructions effectively reduce posterior translation from the deficient-PCL state. In addition, suture augmentation of both techniques provided further anterior-posterior stability.

Ulnar Collateral Ligament Reconstruction Technique Utilizing Suture Tape Augmentation

The prevalence of ulnar collateral ligament injuries and reconstructions among overhead throwing athletes has significantly risen in recent years. Surgical reconstruction has become the main treatment modality for athletes who have failed conservative treatment and wish to return to their sport. There has been an increased interest in graft augmentation in ligament reconstruction surgeries as surgeons search for ways to decrease the chance of graft failure. Augmented graft techniques have been described for other procedures. We present a technique that incorporates a cross-linked suture tape into either a palmaris longus or gracilis tendon autograft or allograft for ulnar collateral ligament reconstruction. This may allow for a biomechanically stronger construct because it appears this is the case in other settings. The goal is that this would lead to decreased rates of failure or possibly allow athletes to return at an accelerated rate.

[Artificial ligaments applied in anterior cruciate ligament repair and reconstruction: Current products and experience]

The application of artificial ligament products in anterior cruciate ligament (ACL) surgeries has gone through a long twisty way. In the 1970s, early artificial ligament products were initially used for ACL surgeries, which showed poor clinical efficacy and eventually ended up in failure. Over the last 20 years, there has been a growing number of ACL reconstruction with new artificial ligament products, including the Leeds-Keio TM, the LARS TM (Ligament Advanced Reinfocement System), and the Trevira Hochfest TM. Among these new products, the LARS TM has been more commonly applied for ACL surgeries. Although these new artificial ligament products have good mechanical properties and show significant improvement of cumulative failure and complication rate, they still have limitations.

Anterior Cruciate Ligament Reconstruction With Suture Tape Augmentation: A Surgical Technique

The anterior cruciate ligament (ACL) is the most common ligamentous knee injury and often is encountered in those participating in multidirectional sports. ACL reconstruction is the most commonly performed knee ligament reconstruction and employs a variety of surgical techniques but still is challenged by residual laxity and graft rupture. To help address and prevent future ACL failures, new repair and reconstruction techniques have been employed that incorporate suture augmentation (InternalBrace; Arthrex, Naples, FL), which protects the graft during healing and ligamentization. Our goal of this article is to provide a surgical technique of suture augmentation with ACL reconstruction.

ACL Reconstruction Using Autologous Hamstrings Augmented With the Ligament Augmentation and Reconstruction System Provides Good Clinical Scores, High Levels of Satisfaction and Return to Sport, and a Low Retear Rate at 2 Years

Background:

There are a number of surgical methods for undertaking anterior cruciate ligament (ACL) reconstruction (ACLR), although relatively high rates of ipsilateral retears and contralateral tears exist, with only 65% of patients returning to their preinjury level of sport. ACLR techniques adopting synthetic augmentation have been proposed in an attempt to improve clinical outcomes and reduce reinjury rates.

Purpose:

To determine the efficacy of ACLR using autologous hamstrings augmented with the Ligament Augmentation and Reconstruction System (LARS).

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 65 patients were prospectively treated with arthroscopically assisted single-bundle ACLR using hamstrings augmented with the LARS, of whom 50 were available for 1- and 2-year reviews. Patient-reported outcome measures (PROMs), KT-1000 arthrometer testing, knee range of motion, peak isokinetic knee strength testing, and a battery of 4 hop tests were employed. Limb symmetry indices (LSIs) were calculated. Analysis of variance was used to evaluate differences over time and between limbs. Data on return to the preinjury level of sport, retears, and reoperations were collected.

Results:

High PROM scores were demonstrated at 1 and 2 years. Before the injury, 47 patients (94%) were actively participating in level 1 or 2 sports, with 38 (76%) and 43 (86%) patients having returned at 1 and 2 years, respectively. Normal (<3 mm; 90%) or nearly normal (3-5 mm; 10%) KT-1000 arthrometer side-to-side differences were observed at 2 years. Apart from knee flexion (P < .0001), extension (P = .001), and the 6-m timed hop (P = .039), there were no between-limb differences at 1 year, and there were no differences on any objective measures at 2 years (all P > .05). Mean LSIs across all measures were ≥90%. At 2 years, 84% to 90% of patients were ≥90% on the hop tests, with 72% and 76% of patients having ≥90% for extension and flexion strength, respectively. Two reoperations were undertaken for meniscal tears (7 and 8.5 months), 1 patient (2%) suffered a retear at 7 months, and 2 patients (3%) suffered a contralateral tear (8 and 12 months).

Conclusion:

This augmented ACLR technique demonstrated good clinical scores, a high rate of return to sport, and low rates of secondary ruptures and contralateral ACL tears at 2 years. Some caution should be noted in interpreting these results, as 15 of 65 patients (23%) were not included in the 2-year follow-up.

In vivo assessment of high-molecular-weight polyethylene core suture tape for intra-articular ligament reconstruction: an animal study

AIMS

Options for the treatment of intra-articular ligament injuries are limited, and insufficient ligament reconstruction can cause painful joint instability, loss of function, and progressive development of degenerative arthritis. This study aimed to assess the capability of a biologically enhanced matrix material for ligament reconstruction to withstand tensile forces within the joint and enhance ligament regeneration needed to regain joint function.

MATERIALS AND METHODS

A total of 18 New Zealand rabbits underwent bilateral anterior cruciate ligament reconstruction by autograft, FiberTape, or FiberTape-augmented autograft. Primary outcomes were biomechanical assessment (n = 17), microCT (µCT) assessment (n = 12), histological evaluation (n = 12), and quantitative polymerase chain reaction (qPCR) analysis (n = 6).

RESULTS

At eight weeks, FiberTape alone or FiberTape-augmented autograft demonstrated increased biomechanical stability compared with autograft regarding ultimate load to failure (p = 0.035), elongation (p = 0.006), and energy absorption (p = 0.022). FiberTape-grafted samples also demonstrated increased bone mineral density in the bone tunnel (p = 0.039). Histological evaluation showed integration of all grafts in the bone tunnels by new bone formation, and limited signs of inflammation overall. A lack of prolonged inflammation in all samples was confirmed by quantification of inflammation biomarkers. However, no regeneration of ligament-like tissue was observed along the suture tape materials. Except for one autograft failure, no adverse events were detected.

CONCLUSION

Our results indicate that FiberTape increases the biomechanical performance of intra-articular ligament reconstructions in a verified rabbit model at eight weeks. Within this period, FiberTape did not adversely affect bone tunnel healing or invoke a prolonged elevation in inflammation. Cite this article: Bone Joint J 2019;101-B:1238-1247.

The Fertilized Anterior Cruciate Ligament: An All-Inside Anterior Cruciate Ligament Reconstruction Augmented With Amnion, Bone Marrow Concentrate, and a Suture Tape

There is increasing research and interest surrounding biologics and sports medicine. Amnion has the potential to decrease adhesions and possibly protect anterior cruciate ligament (ACL) grafts along with increasing vascularization by acting as a scaffold. Bone marrow concentrate containing mesenchymal stem cells combined with Allosync Pure (Arthrex, Naples, FL) injected into ACL tunnels has the potential to increase the speed and quality of graft bone incorporation, especially when used in the setting of a soft-tissue allograft. Using suture tape augmentation (InternalBrace; Arthrex) with the reconstruction has been thought to increase the early strength of the reconstruction. In this article, we combine all 3 techniques into an all-inside ACL reconstruction that has great potential for an earlier return to play and advanced rehabilitation.