Patellar Tendon Graft Anterior Cruciate Ligament Reconstruction Technique With Suture Tape 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.

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

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

The role of peroneus longus (PL) autograft in the reconstruction of anterior cruciate ligament (ACL): A comprehensive narrative review

Background

Peroneus longus tendon (PLT) is a known graft utilised in the ligamentous reconstructions of knee. The current review was performed to analyze the available evidence regarding PLT in the arthroscopic anterior cruciate ligament (ACL) reconstruction.

Methods

A comprehensive search of literature was performed on March 1, 2023 using 5 databases (for manuscripts published between 2010 and 2023). All studies reporting ACL reconstruction with PL graft in adults ≥18 years were considered; and final studies were shortlisted based on specific exclusion criteria.

Results

The search identified 684 articles, among which 26 manuscripts were finally selected. PLT has been used in primary ACL reconstruction (ACLR), revision ACLR, ACLR in multiligamentous injuries and those at risk for anterior knee pain. The full-thickness PLT graft is variable in its dimensions with the mean size ranging between 7 and 8.8 mm (half-PLT grafts ≤8.1 mm). The ultimate strength of doubled PLT graft is significantly higher than native ACL and comparable to the quadrupled hamstring.There was statistically insignificant difference in the laxity and functional outcome of knee following ACLR with PLT, as compared with other autografts (p > 0.05). PLT harvest is associated with satisfactory clinical foot and ankle outcomes, as well as excellent regenerative ability. Overall, studies have demonstrated lower complications with PLT (p < 0.05).

Conclusion

The dimensions of harvested PLT graft are more consistent than HT. It has similar functional outcome and survival, as compared to other autografts. It also has lower risk for donor-site morbidity and lower complications than HT. PLT is a promising, alternative autograft choice in patients undergoing ACLR.

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.

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

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

Suture Tape Augmentation 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.

[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.

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.