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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Synthetic augmentation in ACL reconstruction may reduce re-rupture rates and increase return-to-sport rates: A systematic review and meta-analysis

PURPOSE

Synthetic augmentation (SA) in anterior cruciate ligament reconstruction (ACLR) aims to enhance graft durability, but its benefits remain unclear. To evaluate whether SA in ACLR improves return-to-sport (RTS) rates, reduces graft failure, enhances patient-reported outcomes (PROs) and varies in effectiveness across materials and techniques.

METHODS

A systematic search of five databases was conducted until February 2025. Comparative studies were pooled using Hedges' random-effects meta-analysis with subgroup analysis based on materials and publication year. Non-comparative studies were analysed narratively. Risk of bias was assessed using the Risk of Bias in Non-randomised Studies of Interventions and the Cochrane risk-of-bias tools for randomised studies. Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of evidence.

RESULTS

Forty-seven studies were included (n = 4289): 7 randomised and 40 non-randomised studies (21 comparative; 19 non-comparative). SA systems included InternalBrace (FiberTape, 16 studies), Ligament Augmentation and Reconstruction System (polyester, 5), Ligament Augmentation Device (polyethylene, 18) and other materials (8). GRADE assessment showed moderate-certainty evidence for improved mid-term RTS rate from eight studies (odds ratio [OR]: 1.58; 95% confidence interval (CI): 1.12-2.22; N = 716; I2 = 0%; p = 0.01). Internal brace showed a reduction in re-rupture rates in the long-term (OR: 0.17, 95% CI: 0.04-0.64; N = 218; I2 = 0%; p = 0.01); however, pooled analysis of all techniques showed no statistically significant difference. Contemporary studies showed a better return to sport rates with SA. PROs showed no clinically meaningful differences. Non-comparative studies showed low graft failure rates (<8.7% for InternalBrace; <16.4% for other SA), high RTS rates (>90% for InternalBrace; >56.7% for other SA) and satisfactory PROs.

CONCLUSIONS

SA, particularly InternalBrace, may improve RTS rates and reduce re-rupture risk, though PROs remain inconclusive. Findings are limited by a moderate-to-serious risk of bias, emphasising the need for high-quality research.

LEVEL OF EVIDENCE

Level III.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, systematic review of Level III studies.

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.

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.