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Rilk S, Goodhart GC, O'Brien R, DiFelice GS. Arthroscopic Anatomic Anterior Cruciate Ligament Primary Repair Restores Anterior Tibial Translation Intraoperatively at Time Zero With No Additional Effect of Suture Augmentation. Arthroscopy 2024:S0749-8063(23)00982-9. [PMID: 38266743 DOI: 10.1016/j.arthro.2023.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/10/2023] [Accepted: 11/21/2023] [Indexed: 01/26/2024]
Abstract
PURPOSE To intraoperatively evaluate the ability of anterior cruciate ligament (ACL) primary repair (ACLPR) to restore anterior tibial translation (ATT) at time zero and to assess the influence of additional suture augmentation (SA) on ATT. METHODS Patients with proximal ACL tears undergoing arthroscopic ACLPR with dual-suture anchor fixation were included in this time-zero clinical study. Laxity measurements were taken with a digital arthrometer to evaluate ATT stability preoperatively in the office (T0) as a standardized diagnostic tool, preoperatively under anesthesia (T1), at time zero intraoperatively after ACLPR but prior to SA fixation (T2), and after SA fixation (T3). RESULTS A total of 27 patients (mean age ± standard deviation [SD], 35.1 ± 12.0 years) with proximal ACL tears and significant preoperative (T0) ATT side-to-side differences (SSDs) (mean ± SD, 4.1 ± 1.5 mm) were evaluated. ACLPR was shown to restore ATT SSD at time zero (mean ± SD, 0.2 ± 1.1 mm) given that a significant reduction in ATT SSD (mean difference ± standard error, -4.7 ± 0.21 mm; P < .001) was achieved when comparing preoperative and intraoperative measurements after separate refixation of both ACL bundles with suture anchors. Additional SA fixation did not further decrease ATT when comparing measurements of the ipsilateral leg after ACL refixation and after SA fixation (mean difference ± SD, 0.03 ± 0.22 mm; P = .496). CONCLUSIONS ACLPR with dual-suture anchor fixation restores time-zero ATT laxity in adults with proximal ACL tears. Additional SA fixation in full knee extension does not further decrease ATT. CLINICAL RELEVANCE This study provides important information about the effectiveness of ACLPR in restoring ATT. SA with the knee fixed in full knee extension does not further decrease ATT; therefore, augmentation may not lead to overconstraint of the knee or stress shielding of the repaired ACL.
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Affiliation(s)
- Sebastian Rilk
- Department of Orthopaedic Surgery, Hospital for Special Surgery, NewYork-Presbyterian, Weill Medical College of Cornell University, New York, New York, U.S.A.; Medical University of Vienna, Vienna, Austria
| | - Gabriel C Goodhart
- Department of Orthopaedic Surgery, Hospital for Special Surgery, NewYork-Presbyterian, Weill Medical College of Cornell University, New York, New York, U.S.A
| | - Robert O'Brien
- Department of Orthopaedic Surgery, Hospital for Special Surgery, NewYork-Presbyterian, Weill Medical College of Cornell University, New York, New York, U.S.A.; Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, U.S.A
| | - Gregory S DiFelice
- Department of Orthopaedic Surgery, Hospital for Special Surgery, NewYork-Presbyterian, Weill Medical College of Cornell University, New York, New York, U.S.A..
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Bachmaier S, Smith PA, Hammoud S, Ritter D, Hauck O, Wijdicks CA. Stabilization and Gap Formation of Adjustable Versus Fixed Primary ACL Repair With Internal Brace: An in Vitro Full-Construct Biomechanical Cadaveric Study. Orthop J Sports Med 2023; 11:23259671231201462. [PMID: 37786477 PMCID: PMC10541754 DOI: 10.1177/23259671231201462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/19/2023] [Indexed: 10/04/2023] Open
Abstract
Background A knotless, tensionable primary anterior cruciate ligament (ACL) repair system preloaded with an internal brace has been released. Currently, there is no biomechanical data on the stabilization and gap formation behavior of the adjustable system when compared with fixed repairs in human ACL tissue. Hypothesis That knotless adjustable suture repair with an internal brace would provide overall higher construct stability and greater load share on the ACL with less gap formation compared with fixed repair. Study Design Controlled laboratory study. Methods Human cadaveric knees were utilized for internal braced ACL repair constructs (each group n = 16). Two fixed groups consisting of a single-cinch loop (SCL), cortical button (SCL group), and knotless suture-anchor (anchor group) were compared with an SCL-adjustable loop device (SCL-ALD) group. Testing was performed at 4 different peak loads (50, 150, 250, 350 N) over 4000 cycles at 0.75 Hz including suture repair preconditioning (10 cycles at 0.5 Hz) for SCL-ALD. Specimens were ultimately pulled to failure with a cut internal brace. The final loading situation of the construct and ACL repair with gap formation and ultimate strength were evaluated. Results Peak elongation at various peak loads showed a significantly higher (P < .001) stabilization of SCL-ALD when compared with both fixed groups. There was a significantly higher (P < .001) load share of SCL-ALD, especially at lower loads (48% of 50 N), and the gap formation remained restricted up to 250 N. With only a little load share on the fixed constructs (<6%) at lower loads (50, 150 N), gap formation in these groups started at a load of 150 N, leading to significantly higher gaps (P < .001). The ultimate failure load for SCL-ALD and anchor groups was significantly increased (P < .001) as compared with SCL. The stiffness of SCL-ALD (62.9 ± 10.6 N/mm) was significantly increased (P < .001). Conclusion Internal braced knotless adjustable fixation for ACL repair with preconditioning of the suture repaired ligament increased the overall stabilization with higher load share on the ACL and restricted gap formation (<0.5 mm up to 350 N) compared with fixed suture repair. All internal braced repairs restored stability according to native ACL function. Clinical Relevance Adjustable ACL repair improved the mechanical characteristics and reduced gap formation, but the overall clinical significance on healing remains unclear.
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Affiliation(s)
| | | | - Sommer Hammoud
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Daniel Ritter
- Arthrex Department of Orthopedic Research, Munich, Germany
| | - Oliver Hauck
- Arthrex Department of Orthopedic Research, Munich, Germany
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Kubo T, Takahashi T, Saitsu A, Ae R, Sekiya H, Takeshita K. Material Properties of Suture Augmentation of Knee Medial Collateral Ligament Repair Did Not Influence Length Changes or Failure Loads in a Caged Porcine Model. Arthrosc Sports Med Rehabil 2023; 5:e629-e635. [PMID: 37388876 PMCID: PMC10300545 DOI: 10.1016/j.asmr.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 03/03/2023] [Indexed: 07/01/2023] Open
Abstract
Purpose To investigate whether the biomechanical properties of the healed superficial medial collateral ligament (sMCL) repaired by augmentation vary depending on the material properties of the suture augmentation. Methods In 8 of 10 porcines (16 hindlimbs), the sMCL was detached from the femoral attachment using a scalpel under intubated general anesthesia. sMCL repair was performed using an ultra-high-molecular-weight polyethylene (UHMWPE) tape for the right hindlimbs and polyester tape (PE) for the left hindlimbs. They were sacrificed at 4 weeks postoperatively. The remaining 2 animals were assigned to the native control group (left and right hindlimb; n = 4). All connective tissues and suture augmentation, except for the repaired sMCL, were removed, and their biomechanical properties were evaluated. Results No significant differences were observed in the upper yield load (PE group, 247.4 ± 116.0 N; UHMWPE group, 279.9 ± 95.7 N; and sham group, 231.6 ± 50.6 N; P = .70), maximum yield load (PE group, 310.1 ± 166.1 N; UHMWPE group, 334.6 ± 95.2 N; and sham group, 290.9 ± 42.3 N; P = .84), linear stiffness (PE group, 43.3 ± 16.5 N/mm; UHMWPE group, 52.0 ± 28.2 N/mm; and sham group, 44.7 ± 7.2 N/mm; P = .66), and elongation at failure (PE group, 9.4 ± 4.3 mm; UHMWPE group, 9.1 ± 2.7 mm; and sham group, 10.1 ± 2.1 mm; P = .89). Statistical analysis of failure modes showed no significant difference between the groups (P = .21). Conclusions The material properties of suture augmentation used for sMCL repair did not significantly influence length changes during cyclic loading, postoperative structural properties, or failure modes. Clinical Relevance The results of this study provide valuable information regarding the efficacy of suture augmentation repair regardless of the materials used.
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Affiliation(s)
- Tatsuya Kubo
- Department of Orthopedic Surgery, Shin Kaminokawa Hospital, Kaminokawa, Japan
| | - Tsuneari Takahashi
- Department of Orthopedic Surgery, Ishibashi General Hospital, Shimotsuke, Japan
| | - Akihiro Saitsu
- Department of Orthopaedic Surgery, School of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Ryusuke Ae
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Hitoshi Sekiya
- Department of Orthopedic Surgery, Shin Kaminokawa Hospital, Kaminokawa, Japan
| | - Katsushi Takeshita
- Department of Orthopaedic Surgery, School of Medicine, Jichi Medical University, Shimotsuke, Japan
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A regeneration process-matching scaffold with appropriate dynamic mechanical properties and spatial adaptability for ligament reconstruction. Bioact Mater 2022; 13:82-95. [PMID: 35224293 PMCID: PMC8844703 DOI: 10.1016/j.bioactmat.2021.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/02/2021] [Accepted: 11/02/2021] [Indexed: 12/12/2022] Open
Abstract
Ligament regeneration is a complicated process that requires dynamic mechanical properties and allowable space to regulate collagen remodeling. Poor strength and limited space of currently available grafts hinder tissue regeneration, yielding a disappointing success rate in ligament reconstruction. Matching the scaffold retreat rate with the mechanical and spatial properties of the regeneration process remains challenging. Herein, a scaffold matching the regeneration process was designed via regulating the trajectories of fibers with different degradation rates to provide dynamic mechanical properties and spatial adaptability for collagen infiltration. This core-shell structured scaffold exhibited biomimetic fiber orientation, having tri-phasic mechanical behavior and excellent strength. Besides, by the sequential material degradation, the available space of the scaffold increased from day 6 and remained stable on day 24, consistent with the proliferation and deposition phase of the native ligament regeneration process. Furthermore, mature collagen infiltration and increased bone integration in vivo confirmed the promotion of tissue regeneration by the adaptive space, maintaining an excellent failure load of 67.65% of the native ligament at 16 weeks. This study proved the synergistic effects of dynamic strength and adaptive space. The scaffold matching the regeneration process is expected to open new approaches in ligament reconstruction. Regeneration process-matching scaffold was made via regulating fiber trajectory. The scaffold showed tri-phasic mechanical behavior and fatigue properties. Matching repair process with dynamic mechanical property and spatial adaptability. A feasible substitute for the T/L reconstruction by spatial adaptability.
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Wilson WT, Hopper GP, Banger MS, Blyth MJG, Riches PE, MacKay GM. Anterior cruciate ligament repair with internal brace augmentation: A systematic review. Knee 2022; 35:192-200. [PMID: 35366618 DOI: 10.1016/j.knee.2022.03.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/11/2022] [Accepted: 03/21/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Primary repair of anterior cruciate ligament (ACL) ruptures has re-emerged as a treatment option for proximal tears, with internal brace augmentation often utilised. The aim of this study is to provide an overview of the current evidence presenting outcomes of ACL repair with internal bracing to assess the safety and efficacy of this technique. METHODS All studies reporting outcomes of arthroscopic primary repair of proximal ACL tears, augmented with internal bracing from 2014-2021 were included. Primary outcome was failure rate and secondary outcomes were subjective patient reported outcome measures (PROMs) and objective assessment of anteroposterior knee laxity. RESULTS Nine studies were included, consisting of 347 patients, mean age 32.5 years, mean minimum follow up 2 years. There were 36 failures (10.4%, CI 7.4% - 14.1%). PROMs reporting was variable across studies. KOOS, Lysholm and IKDC scores were most frequently used with mean scores > 87%. The mean Tegner and Marx scores at follow-up were 6.1 and 7.8 respectively. The mean side to side difference measured for anteroposterior knee laxity was 1.2mm. CONCLUSIONS This systematic review with meta-analysis shows that ACL repair with internal bracing is a safe technique for treatment of proximal ruptures, with a failure rate of 10.4%. Subjective scores and clinical laxity testing also revealed satisfactory results. This suggests that ACL repair with internal bracing should be considered as an alternative to ACL reconstruction for acute proximal tears, with the potential benefits of retained native tissue and proprioception, as well as negating the need for graft harvest.
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Affiliation(s)
- W T Wilson
- Department of Biomedical Engineering, University of Strathclyde, Glasgow, UK; NHS Greater Glasgow & Clyde, Glasgow, UK.
| | - G P Hopper
- NHS Greater Glasgow & Clyde, Glasgow, UK.
| | - M S Banger
- Department of Biomedical Engineering, University of Strathclyde, Glasgow, UK.
| | | | - P E Riches
- Department of Biomedical Engineering, University of Strathclyde, Glasgow, UK.
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Muench LN, Berthold DP, Archambault S, Slater M, Mehl J, Obopilwe E, Cote MP, Arciero RA, Chahla J, Lee Pace J. Anterior cruciate ligament (ACL) repair using cortical or anchor fixation with suture tape augmentation vs ACL reconstruction: A comparative biomechanical analysis. Knee 2022; 34:76-88. [PMID: 34875498 DOI: 10.1016/j.knee.2021.09.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 09/05/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose was to compare knee kinematics in a cadaveric model of anterior cruciate ligament (ACL) repair using an adjustable-loop femoral cortical suspensory (AL-CSF) or independent bundle suture anchor fixation (IB-SAF) with suture tape augmentation to a bone-patellar tendon-bone (BPTB) ACL reconstruction. METHODS Twenty-seven cadaveric knees were randomly assigned to one of three surgical techniques: (1) ACL repair using the AL-CSF technique with suture tape augmentation, (2) ACL repair using the IB-SAF technique with suture tape augmentation, (3) ACL reconstruction using a BPTB autograft. Each specimen underwent three conditions according to the state of the ACL (native, proximal transection, repair/reconstruction) with each condition tested at four different angles of knee flexion (0°, 30°, 60°, 90°). Anterior tibial translation (ATT) and internal tibial rotation (ITR) were evaluated using 3-dimensional motion tracking software. RESULTS ACL transection resulted in a significant increase in ATT and ITR when compared to the native state (P < 0.001, respectively). ACL repair with the AL-CSF or IB-SAF technique as well as BPTB reconstruction restored native ATT and ITR at all tested angles of knee flexion, while showing significantly less ATT at 0°, 30°, 60°, and 90° as well as significantly less ITR at 30°, 60°, and 90° of knee flexion when compared to the ACL-deficient state. There were no significant differences in ATT and ITR between the three techniques utilized. CONCLUSION ACL repair using the AL-CSF or IB-SAF technique with suture tape augmentation as well as BPTB ACL reconstruction each restored native anteroposterior and rotational laxity, without significant differences in knee kinematics between the three techniques utilized. LEVEL OF EVIDENCE Controlled Laboratory Study.
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Affiliation(s)
- Lukas N Muench
- Department of Orthopedic Surgery, UConn Health Center, Farmington, CT 06030, United States; Department of Orthopedic Sports Medicine, Technical University of Munich, Germany
| | - Daniel P Berthold
- Department of Orthopedic Surgery, UConn Health Center, Farmington, CT 06030, United States; Department of Orthopedic Sports Medicine, Technical University of Munich, Germany
| | - Simon Archambault
- Department of Orthopedic Surgery, UConn Health Center, Farmington, CT 06030, United States
| | - Maria Slater
- Department of Orthopedic Surgery, UConn Health Center, Farmington, CT 06030, United States
| | - Julian Mehl
- Department of Orthopedic Sports Medicine, Technical University of Munich, Germany
| | - Elifho Obopilwe
- Department of Orthopedic Surgery, UConn Health Center, Farmington, CT 06030, United States
| | - Mark P Cote
- Department of Orthopedic Surgery, UConn Health Center, Farmington, CT 06030, United States
| | - Robert A Arciero
- Department of Orthopedic Surgery, UConn Health Center, Farmington, CT 06030, United States
| | - Jorge Chahla
- Department of Orthopedics, Rush University, Chicago, IL 60612, United States
| | - J Lee Pace
- Department of Orthopedic Surgery, UConn Health Center, Farmington, CT 06030, United States; Elite Sports Medicine @ Connecticut Children's Medical Center, Farmington, CT 06032, United States.
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Szwedowski D, Paczesny Ł, Zabrzyński J, Gagat M, Domżalski M, Huri G, Widuchowski W. The Comparison of Clinical Result between Primary Repair of the Anterior Cruciate Ligament with Additional Internal Bracing and Anatomic Single Bundle Reconstruction-A Retrospective Study. J Clin Med 2021; 10:jcm10173948. [PMID: 34501400 PMCID: PMC8432121 DOI: 10.3390/jcm10173948] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 06/30/2021] [Accepted: 08/23/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The current standard of treatment of anterior cruciate ligament (ACL) is reconstruction (ACLR). This technique has some disadvantages: poor proprioception, donor site morbidity and the inability to restore joint kinematics. ACL repair could be an alternative treatment. The purpose of the study was to compare the stability and the function after ACL primary repair versus single-bundle ACLR. METHODS In a retrospective study, 12 patients underwent primary ACL repair with internal bracing, 15 patients underwent standard ACLR. Follow-up examinations were evaluated at up to 2 years postoperatively. One patient in the ACL repair group was lost to follow-up due to re-rupture. The absolute value of anterior tibial translation (ATT) and the side-to-side difference in the same patient (ΔATT) were evaluated using the GNRB arthrometer. The Lysholm knee scoring was obtained. Re-ruptures and other complications were recorded. RESULTS Anterior tibial translation (ATT) was significantly decreased in the ACL repair group compared with the ACLR group (5.31 mm vs. 7.18 mm, respectively; p = 0.0137). Arthrometric measurements demonstrated a mean side-to-side difference (ΔATT) 1.87 (range 0.2 to 4.9) mm significantly decreased compared to ACLR 3.36 (range 1.2-5.6 mm; p = 0.0107). The mean Lysholm score was 85.3 points in the ACL repair group and 89.9 in ACLR group. No significant differences between ACL repair and ACLR were found for the Lysholm score. There was no association between AP laxity and clinical outcomes. There were two complications in the internal bracing group: one patient had re-rupture and was treated by ACLR, another had limited extension and had arthroscopic debridement. CONCLUSIONS Anterior tibial translation was significantly decreased after ACL repair. Additionally, the functional results after ACL repair with internal bracing were comparable with those after ACLR. It should be noted that the two complications occurred. The current study supports further development of ACL repair techniques.
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Affiliation(s)
- Dawid Szwedowski
- Orthopaedic Arthroscopic Surgery International (OASI) Bioresearch Foundation, 20133 Milan, Italy
- Correspondence:
| | - Łukasz Paczesny
- Citomed Healthcare Center, Department of Orthopaedics, Orvit Clinic, Sklodowskiej 73, 87-100 Toruń, Poland; (Ł.P.); (J.Z.)
| | - Jan Zabrzyński
- Citomed Healthcare Center, Department of Orthopaedics, Orvit Clinic, Sklodowskiej 73, 87-100 Toruń, Poland; (Ł.P.); (J.Z.)
- Department of General Orthopedics, Musculoskeletal Oncology and Trauma Surgery, University of Medical Sciences, 61-701 Poznan, Poland
| | - Maciej Gagat
- Department of Histology and Embryology, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, 85-067 Bydgoszcz, Poland;
| | - Marcin Domżalski
- Department of Orthopedic and Traumatology, Veterans Memorial Hospital, Medical University of Lodz, 90-549 Lodz, Poland;
| | - Gazi Huri
- Orthopaedics and Traumatology Department, Hacettepe Universitesi, Ankara 06100, Turkey;
| | - Wojciech Widuchowski
- Department of the Knee Surgery, Arthroscopy and Sports Traumatology, District Hospital of Orthopedics and Trauma Surgery, 41-940 Piekary Slaskie, Poland;
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Kobayashi EF, Tang K, Grant JA. Is ACL Repair Really Back? A Review of Modern Techniques. OPER TECHN SPORT MED 2021. [DOI: 10.1016/j.otsm.2021.150828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Burton DA, Schaefer EJ, Shu HT, Bodendorfer BM, Argintar EH. Primary Anterior Cruciate Ligament Repair Using Suture Tape Augmentation: A Case Series of 29 Patients With Minimum 2-Year Follow-Up. Arthroscopy 2021; 37:1235-1241. [PMID: 33581301 DOI: 10.1016/j.arthro.2020.11.034] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate clinical outcomes and patient-reported outcomes of patients who underwent primary anterior cruciate ligament (ACL) repair using suture tape augmentation. METHODS Patients with a proximal tear of the ACL who underwent primary ACL repair with a minimum 2-year follow-up were included. The exclusion criteria included multiligamentous knee injuries, midsubstance tears, tibial avulsion fractures, and distal tears. Demographic characteristics, injury pattern, concomitant injury pattern, and patient-reported outcome measures were recorded. Patients were evaluated at a minimum 2-year follow-up for clinical success, defined as stability not requiring revision ACL reconstruction, and for patient-reported outcome measurements. Failure was defined as the need for revision surgery. RESULTS The mean follow-up period was 2.8 ± 0.9 years. Thirty-five patients met the inclusion criteria, with an average age of 32.2 ± 7.2 years, and 2-year follow-up was obtained for 29 of these patients. Revision surgery was required in 2 of the 29 patients (6.9%); successful treatment was achieved in the remaining 93.1%. The Single Assessment Numeric Evaluation score and Knee Injury and Osteoarthritis Outcome Score for the 27 successfully treated patients were recorded, with 70.4% having Single Assessment Numeric Evaluation scores of 80 or greater. CONCLUSIONS This case series shows that primary surgical repair of proximal ACL tears using suture tape augmentation results in a low rate of revision surgery. LEVEL OF EVIDENCE Level IV, prospective case series.
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Affiliation(s)
- Denver A Burton
- Department of Orthopaedic Surgery, Georgetown University Medical Center, Washington, DC, U.S.A..
| | | | - Henry T Shu
- Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Blake M Bodendorfer
- Department of Orthopaedic Surgery, Georgetown University Medical Center, Washington, DC, U.S.A
| | - Evan H Argintar
- Department of Orthopaedic Surgery, MedStarWashington Hospital Center, Washington, DC, U.S.A
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Batista JP, Chahla J, Dalmau-Pastor M, Maestu R, Kunze KN, Guelfi M. Arthroscopic anterior cruciate ligament repair with and without suture augmentation: technical note. J ISAKOS 2021; 6:251-256. [PMID: 34272302 DOI: 10.1136/jisakos-2020-000508] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 12/27/2020] [Accepted: 01/20/2021] [Indexed: 01/11/2023]
Abstract
Anterior cruciate ligament (ACL) tears are routinely treated with an ACL reconstruction. This is based on historical literature reporting high failure rates after ACL repairs in addition to the limited healing potential of the ACL. Recently, improved understanding of pathophysiology of ligamentous healing has led to increasing interest in treating proximal avulsions with excellent tissue quality in the acute setting, as this technique allows for ACL healing. Potential advantages of ACL repair include preservation of native proprioceptive and kinematics of the knee, avoidance of graft harvesting morbidity and the possibility to perform a primary ACL reconstruction in case of failure. As a consequence, several techniques for ACL repair have been proposed that can be performed in isolation or with suture augmentation. The primary aim of this technical note is to describe step-by-step the ACL repair technique with and without suture augmentation. The secondary aim of the current study is to review the indications, patient selection and advantages of the technique.
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Affiliation(s)
- Jorge Pablo Batista
- Department of Arthroscopy, Centro Artroscopico Jorge Batista SA, Buenos Aires, CABA, Argentina.,Sports Medicine Department, Club Atletico Boca Juniors, Buenos Aires, CABA, Argentina
| | - Jorge Chahla
- Midwest Orthopaedics, Rush University Medical Center, Chicago, Illinois, USA
| | - Miki Dalmau-Pastor
- Human Anatomy Unit, University of Barcelona Faculty of Medicine, Barcelona, Catalunya, Spain.,GRECMIP-MIFAS (Groupe de Recherche et d'Etude en Chirurgie Mini-Invasive du Pied-Minimally Invasive Foot and Ankle Society), Merignac, France
| | - Rodrigo Maestu
- Centro de Estudios y Tratamiento de Enfermemades Articulares, Buenos Aires, CABA, Argentina
| | - Kyle N Kunze
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Matteo Guelfi
- Department of Orthopaedic Surgery, Casa di Cura Villa Montallegro, Genoa, Italy .,Department of Orthopaedic Surgery, Gruppo Policlinico di Monza, Alessandria, Italy.,Human Anatomy and Embryology Unit, Department of Morphological Sciences, Universitat Autònoma de Barcelona, Barcelona, Spain
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Daggett MC, Busch K, Ferretti A, Monaco E, Bruni G, Saithna A. Percutaneous Anterior Cruciate Ligament Repair With Needle Arthroscopy and Biological Augmentation. Arthrosc Tech 2021; 10:e289-e295. [PMID: 33680758 PMCID: PMC7917016 DOI: 10.1016/j.eats.2020.10.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 10/08/2020] [Indexed: 02/03/2023] Open
Abstract
Recent advancements in orthopaedic devices have instilled a renewed interest in repair of the anterior cruciate ligament. Biological augmentation of the repair has also recently been investigated with the hopes of improving repair outcomes and improving biological healing. The advent of needle arthroscopy allows for potentially decreased recovery times and potentially reduced complication rates compared with traditional arthroscopy. The purpose of this article is to present a percutaneous technique to repair the anterior cruciate ligament with suture tape augmentation while also augmenting with the biological byproducts from the native effusion using needle arthroscopy.
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Affiliation(s)
- Matthew C. Daggett
- Address correspondence to Matthew C. Daggett, D.O., M.B.A., 2000 SE Blue Pkwy, Ste 230, Lee's Summit, MO 64063, U.S.A.
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12
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Suture Tape Augmentation Has No Effect on Anterior Tibial Translation, Gap Formation, or Load to Failure of Anterior Cruciate Ligament Repair: A Biomechanical Pilot Study. Arthrosc Sports Med Rehabil 2021; 3:e233-e239. [PMID: 33615270 PMCID: PMC7879211 DOI: 10.1016/j.asmr.2020.09.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 09/19/2020] [Indexed: 12/15/2022] Open
Abstract
Purpose The purpose of our pilot study was to assess the effect of augmenting anterior cruciate ligament (ACL) repair with suture tape on biomechanical parameters including anterior tibial translation, gap formation, and load to failure. Methods Ten fresh-frozen nonpaired cadaveric knees were dissected, and baseline anterior-posterior stability of both ACL-intact and -deficient knees was obtained. The specimens were randomized to undergo ACL repair either with or without suture tape reinforcement, and anterior tibial translation, as well as gap formation, was measured after cyclic loading. Finally, all specimens were subjected to a single pullout force to determine maximum load to failure. We performed t test analysis to compare means between groups, and significance was defined as P < .05. Results On t test analysis, no statistically significant difference was found regarding anterior tibial translation between the ACL-intact group and either repair group or between the repair group without suture tape augmentation and the repair group with suture tape augmentation. No significant difference in gap formation was detected between the repair groups with and without suture tape augmentation at 100 cycles (1.25 mm vs 1.02 mm, P = .6), 250 cycles (2.87 mm vs 2.12 mm, P = .3), and 500 cycles (4.5 mm vs 4.55 mm, P = .5). The average load to failure of the repairs without suture tape augmentation was not significantly different from that of the repairs with suture tape augmentation (725.9 N vs 725.7 N, P = .99). Conclusions In this pilot study, we did not identify a difference between ACL repairs with and without suture tape augmentation regarding anterior tibial translation, gap formation, or maximum load to failure. Clinical Relevance Treatment of ACL tears with primary ACL repair is a highly debated topic, and studies such as this study to further our understanding of the biomechanical properties of augmented ACL repairs are important for surgeons when deciding the best treatments for their patients.
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Hughes JD, Lawton CD, Nawabi DH, Pearle AD, Musahl V. Anterior Cruciate Ligament Repair: The Current Status. J Bone Joint Surg Am 2020; 102:1900-1915. [PMID: 32932291 DOI: 10.2106/jbjs.20.00509] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jonathan D Hughes
- UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Cort D Lawton
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY
| | - Danyal H Nawabi
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY
| | - Andrew D Pearle
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY
| | - Volker Musahl
- UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania
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Vermeijden HD, Jonkergouw A, van der List JP, DiFelice GS. The multiple ligament-injured knee: When is primary repair an option? Knee 2020; 27:173-182. [PMID: 31926671 DOI: 10.1016/j.knee.2019.11.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 10/23/2019] [Accepted: 11/23/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Treatment of multiple ligament-injured knees (MLIKs) remains complex and most often requires ligament reconstruction surgery. Reconstruction effectively restores knee stability but the procedure is invasive and can be complicated by stiffness or arthrofibrosis. There has been recent resurgence of interest in primary repair of knee ligaments. The goal was therefore to assess incidence of repairable ligaments in MLIKs, and determine patient and injury characteristics associated with potential for primary repair. METHODS A retrospective review of all MLIK patients surgically treated between 2009 and 2018 was conducted. All patients were treated with the same algorithm: primary repair was performed if the ligament was proximally or distally avulsed, and otherwise, reconstruction was performed. Patient characteristics, injury patterns, treatment specifics, and short-term outcomes were compared using independent t-tests and chi-square tests. RESULTS Forty-eight patients were included (mean age 32 years ± 14; 54% were male). Ultimately, 55% of ACL, 73% of PCL, 88% of MCL/PMC, and 87% of LCL/PLC injuries were repaired. Patients above 35 years (OR 6.9, P = 0.010) and higher BMI (OR 3.5, P = 0.046) were more likely to undergo ACL repair. No significant correlation was found in other ligaments. At a minimum of six-month follow-up (range 0.5-7.2 years), ACL repair failed in nine percent, PCL repair in 17%, MCL/PMC repair in 0%, and LCL/PLC repair in 18% of patients. CONCLUSIONS This study noted high incidences of repairable ligaments when MLIKs are treated within six weeks following injury. Although preliminary outcomes following primary repair in MLIK are good, further long-term follow-up studies are needed.
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Affiliation(s)
- Harmen D Vermeijden
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, NewYork-Presbyterian, Weill Medical College of Cornell University, 535 E. 70th Street, New York, NY 10021, United States.
| | - Anne Jonkergouw
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, NewYork-Presbyterian, Weill Medical College of Cornell University, 535 E. 70th Street, New York, NY 10021, United States
| | - Jelle P van der List
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, NewYork-Presbyterian, Weill Medical College of Cornell University, 535 E. 70th Street, New York, NY 10021, United States; Amsterdam UMC, University of Amsterdam Department of Orthopaedic Surgery, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Gregory S DiFelice
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, NewYork-Presbyterian, Weill Medical College of Cornell University, 535 E. 70th Street, New York, NY 10021, United States.
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Hoogeslag RAG, Brouwer RW, Huis In 't Veld R, Amis AA. Isometric placement of the augmentation braid is not attained reliably in contemporary ACL suture repair. Knee 2020; 27:111-123. [PMID: 31791721 DOI: 10.1016/j.knee.2019.10.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 10/18/2019] [Accepted: 10/20/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND To assess if during arthroscopic braid-augmented ACL suture repair (ACLSR), the actual positions of the augmentation braids' tunnels corresponded with the positions of their intended and targeted isometric points, and to test the hypothesis that there would be no dispersion in actual positions of the augmentation braids' tunnels compared to their intended and targeted isometric points. METHODS In 12 human cadaveric knees, the positions of the augmentation braids' tunnels and their intended and targeted isometric points relative to a femoral and tibial grid were analysed. Furthermore, vector length between these positions was calculated to assess the accuracy and precision of the augmentation braids' tunnel placement. RESULTS There was dispersion for all of the augmentation braids' tunnel positions compared to their intended isometric points. The femoral and tibial vector lengths (mean ± SD (range)) were 2.9 ± 1.0 (1.1-4.1) and 7.1 ± 2.0 (3.2-9.8) mm respectively. CONCLUSION In augmented ACLSR, with the ruptured ACL in situ, there was dispersion of the positions of the actual small diameter femoral and tibial augmentation braids' tunnels away from their desired isometric points. CLINICAL RELEVANCE The extent of dispersion of the position of both the femoral and tibial tunnels away from their intended isometric positions may cause cyclic length changes with knee motion. An ACLSR with static braid augmentation will thus be vulnerable to cyclic stretching-out. The difficulty of obtaining an isometric tunnel combination for the small diameter augmentation braid may influence the clinician's choice between non-, static or dynamic augmented ACLSR techniques.
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Affiliation(s)
- Roy A G Hoogeslag
- Department of Mechanical Engineering, Imperial College London, London SW7 2AZ, UK.
| | - Reinoud W Brouwer
- Department of Mechanical Engineering, Imperial College London, London SW7 2AZ, UK.
| | | | - Andrew A Amis
- Department of Mechanical Engineering, Imperial College London, London SW7 2AZ, UK; Musculoskeletal Surgery Group, Imperial College London School of Medicine, Charing Cross Hospital, London W6 8RF, UK.
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Bachmaier S, DiFelice GS, Sonnery-Cottet B, Douoguih WA, Smith PA, Pace LJ, Ritter D, Wijdicks CA. Treatment of Acute Proximal Anterior Cruciate Ligament Tears-Part 2: The Role of Internal Bracing on Gap Formation and Stabilization of Repair Techniques. Orthop J Sports Med 2020; 8:2325967119897423. [PMID: 32064294 PMCID: PMC6987493 DOI: 10.1177/2325967119897423] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 09/18/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The latest biomechanical studies on some form of internal bracing have shown improved stabilization for anterior cruciate ligament (ACL) repair, but gap formation and load-sharing function have not yet been reported. HYPOTHESIS Internal bracing of an adjustable ACL repair construct provides improved stabilization with reduced gap formation and higher residual loading on the ACL. STUDY DESIGN Controlled laboratory study. METHODS Internally braced ACL repair constructs with single- and double-cinch loop (CL) cortical buttons, a knotless suture anchor, and a single-CL cortical button with adjustable loop fixation (CLS-ALD) were tested (n = 20 each) in a porcine model at 4 different loads (n = 5 each) over 4000 cycles at 0.75 Hz (n = 80 total). The CLS-ALD technique allowed for additional preconditioning (10 cycles at 0.5 Hz). Test results of the isolated internal brace groups served as a baseline for comparison. Lastly, specimens were pulled to failure (50 mm/min) with a cut internal brace. Final loading and gap formation on the ACL repair construct as well as ultimate strength were analyzed. RESULTS A statistical significance for peak loads over peak elongation was found between the CLS-ALD and all other reinforced groups (analysis of covariance, P < .001). Accordingly, the adjustable repair technique showed improved load-bearing capability with the internal brace compared with all other fixed repair groups and revealed significantly higher loads than the knotted single-CL group. Also, significantly reduced gap formation was found for the CLS-ALD compared with all other groups (P < .001), with no gap formation up to 150 N with a final gap of 0.85 ± 0.31 mm at 350 N. A significantly higher ultimate failure load (866.2 ± 104.0 N; P < .001) was found for the button-fixed internal brace group compared with all other groups. CONCLUSION Internal bracing had a crucial role in improving the stabilization potential of ACL repair at loads occurring during normal daily activity. The added strength of the internal brace allowed for reducing peak loads on the ACL repair construct as well as restricting gap formation to below 3 mm at loads up to 350 N. CLINICAL RELEVANCE Improvements in the mechanical characteristics of current ACL repair techniques that enable reduced gap formation and allow for early range of motion and accelerated rehabilitation may strengthen the self-healing response with the formation of stable scar tissue.
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Affiliation(s)
| | | | | | - Wiemi A. Douoguih
- MedStar Washington Hospital Center, Washington, District of
Columbia, USA
| | | | - Lee J. Pace
- Connecticut Children’s Specialty Group, Hartford, Connecticut,
USA
| | - Daniel Ritter
- Department of Orthopedic Research, Arthrex, Munich, Germany
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Anderson SR, Youssefzadeh KA, Limpisvasti O. Anterior Cruciate Ligament Reconstruction With Suture Tape Augmentation: A Surgical Technique. Arthrosc Tech 2019; 8:e1579-e1582. [PMID: 31890540 PMCID: PMC6928457 DOI: 10.1016/j.eats.2019.08.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 08/16/2019] [Indexed: 02/03/2023] Open
Abstract
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.
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Affiliation(s)
- Scott Richard Anderson
- Address correspondence to Scott Richard Anderson, M.D., Cedars-Sinai Kerlan-Jobe Orthopaedic Institute, 6801 Park Terrace, Los Angeles, CA 90045.
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Arthroscopic primary repair of proximal anterior cruciate ligament tears: outcomes of the first 56 consecutive patients and the role of additional internal bracing. Knee Surg Sports Traumatol Arthrosc 2019; 27:21-28. [PMID: 30612165 DOI: 10.1007/s00167-018-5338-z] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 12/07/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Recent outcomes of arthroscopic primary repair of proximal anterior cruciate ligament (ACL) tears have been promising in small cohort studies. The purpose of this study was to assess outcomes of arthroscopic ACL repair in a larger cohort and to assess the role of additional augmentation. METHODS The first 56 consecutive patients that underwent arthroscopic ACL repair were examined at minimum 2-year follow-up. The latter 27 patients [48.2% (27/56)] received additional internal bracing with ACL repair. All 56 patients were included (100% follow-up). Mean age at surgery was 33.5 ± 11.3 years (59% male) and mean follow-up 3.2 ± 1.7 years. Clinical examination was performed using the objective International Knee Documentation Committee (IKDC) form. Subjective outcomes were obtained using the Lysholm, modified Cincinnati, Single Assessment Numeric Evaluation (SANE), and subjective IKDC scores. RESULTS Six repairs (10.7%) failed and four additional patients underwent reoperation (7.1%): two for meniscus tears and two for suture anchor irritation. Objective IKDC scores were A in 38 (73%), B in 8 (15%) and C/D in 6 (12%) patients. Mean Lysholm score was 94 ± 7.6, modified Cincinnati 94 ± 8.9, SANE 90 ± 12.5, pre-injury Tegner 6.7 ± 1.5, current Tegner 6.2 ± 1.5, and subjective IKDC 90 ± 10.9. Failures rates were 7.4% with and 13.8% without internal bracing (P = 0.672). There were no statistically significant or clinically relevant differences in subjective outcomes. CONCLUSION Arthroscopic primary repair has resulted in good objective and subjective outcomes at 3.2-year follow-up in a carefully selected population. The role of additional internal bracing is possibly beneficial, but larger groups are needed to assess this. LEVEL OF EVIDENCE III.
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van Eck CF, Limpisvasti O, ElAttrache NS. Is There a Role for Internal Bracing and Repair of the Anterior Cruciate Ligament? A Systematic Literature Review. Am J Sports Med 2018; 46:2291-2298. [PMID: 28783472 DOI: 10.1177/0363546517717956] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Renewed interest has arisen in arthroscopic anterior cruciate ligament (ACL) repair techniques. HYPOTHESIS ACL repair with or without some form of internal bracing could lead to good outcomes in a carefully selected subset of patients. STUDY DESIGN Systematic review. METHODS An electronic database search was performed to identify 89 papers describing preclinical and clinical studies on the outcome of ACL repair. RESULTS Proximal ACL tear patterns showed a better healing potential with primary repair than distal or midsubstance tears. Some form of internal bracing increased the success rate of ACL repair. Improvement in the biological characteristics of the repair was obtained by bone marrow access by drilling tunnels or microfracture. Augmentation with platelet-rich plasma was beneficial only in combination with a structural scaffold. Skeletally immature patients had the best outcomes. Acute repair offered improved outcomes with regard to load, stiffness, laxity, and rerupture. CONCLUSION ACL repair may be a viable option in young patients with acute, proximal ACL tears. The use of internal bracing, biological augmentation, and scaffold tissue may increase the success rate of repair.
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Affiliation(s)
| | - Orr Limpisvasti
- Kerlan Jobe Orthopaedic Clinic, Los Angeles, California, USA
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20
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Mahapatra P, Horriat S, Anand BS. Anterior cruciate ligament repair - past, present and future. J Exp Orthop 2018; 5:20. [PMID: 29904897 PMCID: PMC6002325 DOI: 10.1186/s40634-018-0136-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 05/31/2018] [Indexed: 12/14/2022] Open
Abstract
Background This article provides a detailed narrative review on the history and current concepts surrounding ligamentous repair techniques in athletic patients. In particular, we will focus on the anterior cruciate ligament (ACL) as a case study in ligament injury and ligamentous repair techniques. PubMed (MEDLINE), EMBASE and Cochrane Library databases for papers relating to primary anterior cruciate ligament reconstruction were searched by all participating authors. All relevant historical papers were included for analysis. Additional searches of the same databases were made for papers relating to biological enhancement of ligament healing. Current standard The poor capacity of the ACL to heal is one of the main reasons why the current gold standard surgical treatment for an ACL injury in an athletic patient is ACL reconstruction with autograft from either the hamstrings or patella tendon. It is hypothesised that by preserving and repairing native tissues and negating the need for autograft that primary ACL repair may represent a key step change in the treatment of ACL injuries. History of primary ACL repair The history of primary ACL repair will be discussed and the circumstances that led to the near-abandonment of primary ACL repair techniques will be reviewed. New primary repair techniques There has been a recent resurgence in interest with regards to primary ACL repair. Improvements in imaging now allow for identification of tear location, with femoral-sided injuries, being more suitable for repair. We will discuss in details strategies for improving the mechanical and biological environment in order to allow primary healing to occur. In particular, we will explain mechanical supplementation such as Internal Brace Ligament Augmentation and Dynamic Intraligamentary Stabilisation techniques. These are novel techniques that aim to protect the primary repair by providing a stabilising construct that connects the femur and the tibia, thus bridging the repair. Bio enhanced repair In addition, biological supplementation is being investigated as an adjunct and we will review the current literature with regards to bio-enhancement in the form platelet rich plasma, bio-scaffolds and stem cells. On the basis of current evidence, there appears to be a role for bio-enhancement, however, this is not yet translated into clinical practice. Conclusions Several promising avenues of further research now exist in the form of mechanical and biological augmentation techniques. Further work is clearly needed but there is renewed interest and focus for primary ACL repair that may yet prove the new frontier in ligament repair.
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Affiliation(s)
- Piyush Mahapatra
- Trauma and Orthopaedic Department, Croydon University Hospital, 530 London Road, London, CR7 7YE, UK.
| | - Saman Horriat
- Trauma and Orthopaedic Department, Croydon University Hospital, 530 London Road, London, CR7 7YE, UK
| | - Bobby S Anand
- Trauma and Orthopaedic Department, Croydon University Hospital, 530 London Road, London, CR7 7YE, UK
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van der List JP, DiFelice GS. Arthroscopic Primary Anterior Cruciate Ligament Repair With Suture Augmentation. Arthrosc Tech 2017; 6:e1529-e1534. [PMID: 29354469 PMCID: PMC5709701 DOI: 10.1016/j.eats.2017.06.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 06/06/2017] [Indexed: 02/06/2023] Open
Abstract
Historically, poor results of open primary repair of anterior cruciate ligament (ACL) injuries have been reported. In hindsight, however, appropriate patient selection (i.e. proximal tears and good tissue quality) was not performed, because it has recently been recognized that good outcomes of primary ACL repair are possible when selectively performed in patients with proximal tears and good tissue quality. Moreover, with modern-day advances, arthroscopic primary repair can be an excellent treatment option for patients with proximal tears. Preserving the native ACL has several advantages, including maintaining native proprioceptive function and biology. The procedure is also minimally invasive and prevents the need for formal ACL reconstruction. Recently, it has been suggested that additional suture augmentation of the primary repair technique may be beneficial for protecting ligament healing during early range of motion. In this Technical Note, we present the surgical technique of arthroscopic primary repair with suture augmentation for patients with proximal ACL tears.
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Affiliation(s)
- Jelle P. van der List
- Address correspondence to Jelle P. van der List, M.D., Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 E. 70th Street, New York, NY 10021, U.S.A.Orthopaedic Trauma ServiceDepartment of Orthopaedic SurgeryHospital for Special Surgery535 E. 70th StreetNew YorkNY10021U.S.A.
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van der List JP, DiFelice GS. Gap formation following primary repair of the anterior cruciate ligament: A biomechanical evaluation. Knee 2017; 24:243-249. [PMID: 27955813 DOI: 10.1016/j.knee.2016.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 10/03/2016] [Accepted: 10/19/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Historically, inconsistent and unpredictable results of open primary anterior cruciate ligament (ACL) repair were reported. Recently, however, good results of arthroscopic primary ACL repair of proximal tears have been reported. Purpose of this study was to assess the direct postoperative gap formation and maximum failure load following simulated knee motion after primary ACL repair. METHODS Six matched-paired human cadaveric knees (mean age: 52years, range: 48 to 56years) were used. After primary proximal ACL repair with either suture button fixation or suture anchor fixation, knees were cycled five, 50 and 100 times with a simulated active quadriceps force. Gap formation between the femoral wall and ligament was measured using a digital caliper and maximum failure load was tested. RESULTS Gap formation after five, 50 and 100cycles of the knee were 0.30mm (±0.23), 0.75mm (±0.55) and 0.97mm (±0.70), respectively, with no significant differences between both fixation techniques. The overall maximum failure load was 243N (±143) with no difference between both techniques. Most common failure mode was slipping of suture from the fixation. CONCLUSION Following proximal ACL repair, gap formation of approximately one millimeter was measured after repetitious knee cycling with mean maximum failure load of 243N. These findings are likely to be sufficient for careful early active range of motion (ROM) when extrapolating from other available studies. Future studies with second-look arthroscopy are necessary to assess the gap formation and healing in patients treated with primary repair.
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Affiliation(s)
- Jelle P van der List
- Orthopaedic Sports Medicine and Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, NewYork-Presbyterian, Weill Medical College of Cornell University, New York, NY, United States; Hospital for Special Surgery, 535 E. 70th Street, New York, NY 10021, United States.
| | - Gregory S DiFelice
- Orthopaedic Sports Medicine and Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, NewYork-Presbyterian, Weill Medical College of Cornell University, New York, NY, United States; Hospital for Special Surgery, 535 E. 70th Street, New York, NY 10021, United States.
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Gurlek AC, Sevinc B, Bayrak E, Erisken C. Synthesis and characterization of polycaprolactone for anterior cruciate ligament regeneration. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2016; 71:820-826. [PMID: 27987777 DOI: 10.1016/j.msec.2016.10.071] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 09/18/2016] [Accepted: 10/13/2016] [Indexed: 10/20/2022]
Abstract
Anterior cruciate ligament (ACL) is the most frequently torn ligament in the knee, and complete healing is unlikely due to lack of vascularization. Current approaches for the treatment of ACL injuries include surgical interventions and grafting, however recent reports show that surgeries have 94% recurrency, and that repaired tissues are biomechanically inferior to the native tissue. These necessitate the need for new strategies for scar-free repair/regeneration of ACL injuries. Polycaprolactone (PCL) is a biodegradable and biocompatible synthetic polymer, which has been widely used in the connective tissue repair/regeneration attempts. Here, we report on the synthesis of PCL via ring opening polymerization using ε-caprolactone as the monomer, and ammonium heptamolybdate as a catalyst. The synthesized PCL was characterized using Fourier Transform Infrared Spectroscopy (FTIR) and Nuclear Magnetic Resonance (NMR) spectroscopy. It was then processed using electrospinning to form nanofiber-based scaffolds. These scaffolds were characterized in terms of surface as well as mechanical properties, and compared to the properties of commercially available PCL, and of native ACL tissue harvested from sheep. In addition, scaffolds fabricated with synthesized PCL were evaluated regarding their cell attachment capacity using human bone marrow mesenchymal stem cells (hBMSCs). Our findings demonstrated that the synthesized PCL is similar to its commercially available counterpart in terms of surface morphology and mechanical properties. In addition, fibrous scaffolds generated with electrospinning showed weaker mechanical properties visa vis native ACL tissue in terms of ultimate stress, and elastic modulus. Also, the synthesized PCL can accommodate cell attachment when tested with hBMSCs. Putting together, these observations reveal that the PCL synthesized in this study could be a good candidate as a biomaterial for ligament repair or regeneration.
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Affiliation(s)
- Ayse Cansu Gurlek
- Department of Biomedical Engineering, TOBB University of Economics and Technology, Ankara, Turkey
| | - Burcu Sevinc
- Department of Biomedical Engineering, TOBB University of Economics and Technology, Ankara, Turkey
| | - Ece Bayrak
- Department of Biomedical Engineering, TOBB University of Economics and Technology, Ankara, Turkey
| | - Cevat Erisken
- Department of Biomedical Engineering, TOBB University of Economics and Technology, Ankara, Turkey.
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Taylor SA, Khair MM, Roberts TR, DiFelice GS. Primary Repair of the Anterior Cruciate Ligament: A Systematic Review. Arthroscopy 2015; 31:2233-47. [PMID: 26165465 DOI: 10.1016/j.arthro.2015.05.007] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 04/13/2015] [Accepted: 05/13/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To describe the clinical and preclinical research conducted on primary repair of the anterior cruciate ligament (ACL) during the past 10 years. METHODS A systematic search of PubMed, the Cochrane Central Register of Controlled Trials, and Embase was performed for all English-language studies published between 2003 and April 2014 on primary repair of the ACL. RESULTS Twenty-six studies met the inclusion and exclusion criteria. In the clinical research group, 8 studies (166 patients; age range, 10 to 71 years) met the inclusion and exclusion criteria and were largely long-term clinical outcome studies, based on the original cohorts from the 1970s and 1980s, and suggested high failure rates, additional surgery, and revision for instability. A subset of patients, however, achieved good to excellent subjective and objective long-term outcomes. In the preclinical research group, 18 studies met the inclusion and exclusion criteria and were based on an ACL transection model; they suggested that (1) stabilization of the knee with an internal suture strut improved the healing and biomechanical properties of the repaired ACL, (2) "enhancing" the repair with biological collagen-platelet composite augmentation improved healing and mechanical strength, (3) younger age and skeletal immaturity seem to correlate with improved histologic healing and biomechanical properties, (4) enhanced primary repair of the ACL may reduce post-traumatic osteoarthritis, and (5) the native ACL biomechanically outperformed the repaired ACL. CONCLUSIONS Although long-term human studies suggest collectively unacceptable outcomes for open primary repair of the ACL, a subset of patients achieved acceptable long-term results. ACL transection model animal studies showed improved healing and biomechanics with primary suture repair stabilization, early intervention, biological augmentation techniques, and younger age. Primary repair of the ACL may be an effective treatment modality for an appropriately selected subset of patients. LEVEL OF EVIDENCE Level IV, systematic review of preclinical and clinical Level IV studies.
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Affiliation(s)
- Samuel A Taylor
- Orthopaedic Trauma and Sports Medicine Services, Hospital for Special Surgery, New York, New York, U.S.A
| | - M Michael Khair
- Orthopaedic Trauma and Sports Medicine Services, Hospital for Special Surgery, New York, New York, U.S.A
| | - Timothy R Roberts
- Orthopaedic Trauma and Sports Medicine Services, Hospital for Special Surgery, New York, New York, U.S.A
| | - Gregory S DiFelice
- Orthopaedic Trauma and Sports Medicine Services, Hospital for Special Surgery, New York, New York, U.S.A..
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Nau T, Teuschl A. Regeneration of the anterior cruciate ligament: Current strategies in tissue engineering. World J Orthop 2015; 6:127-136. [PMID: 25621217 PMCID: PMC4303781 DOI: 10.5312/wjo.v6.i1.127] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 06/19/2014] [Accepted: 07/29/2014] [Indexed: 02/06/2023] Open
Abstract
Recent advancements in the field of musculoskeletal tissue engineering have raised an increasing interest in the regeneration of the anterior cruciate ligament (ACL). It is the aim of this article to review the current research efforts and highlight promising tissue engineering strategies. The four main components of tissue engineering also apply in several ACL regeneration research efforts. Scaffolds from biological materials, biodegradable polymers and composite materials are used. The main cell sources are mesenchymal stem cells and ACL fibroblasts. In addition, growth factors and mechanical stimuli are applied. So far, the regenerated ACL constructs have been tested in a few animal studies and the results are encouraging. The different strategies, from in vitro ACL regeneration in bioreactor systems to bio-enhanced repair and regeneration, are under constant development. We expect considerable progress in the near future that will result in a realistic option for ACL surgery soon.
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Almeida D, Barletta M, Mathews L, Graham L, Quandt J. Comparison between invasive blood pressure and a non-invasive blood pressure monitor in anesthetized sheep. Res Vet Sci 2014; 97:582-6. [DOI: 10.1016/j.rvsc.2014.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 07/24/2014] [Accepted: 10/05/2014] [Indexed: 10/24/2022]
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