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Apostolakos JM, Garcia AR, Buchalter WH, Hollenbeck JF, Hackett TR, Viola RW. The effect of number of knots per throw, knot technique, and suture type on strength properties of suspensory fixation button surgical procedures. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:424-430. [PMID: 39157243 PMCID: PMC11329005 DOI: 10.1016/j.xrrt.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Abstract
Background Previous studies of the cortical suspensory button (CSB) implant have analyzed fixation strength as a function of suture type and surgical technique, but knot configuration remains an area of interest. This study investigates 4-strand knot configurations in CSB suspensory fixation, specifically comparing the use of 2 separate knots with a single knot. We hypothesize that using 2 knots on the distal side of the CSB with #2 suture will yield the strongest and stiffest suspensory fixation. Methods Two types of knot configurations were compared: a single knot with all 4 suture strands versus 2 independent knots with 2 suture strands each (1 knot from inner strands and 1 knot from outer strands). They were tested using #2 or 2-0 suture, and at distal (on top of the button) or proximal (underneath the button) knot positions. Mechanical testing on the Instron measured ultimate failure load, elongation at failure, and stiffness. Statistical analyses (Shapiro-Wilk, unpaired Student's t-tests, and Chi-square tests) assessed differences in strength, stiffness, elongation, and failure mode between knot configurations within each CSB construct combination. Results With #2 suture, 2 knots across the CSB resulted in higher load to failure compared to 1 knot in both proximal (467.00 N vs. 554.66 N, P = .026) and distal (395.18 N vs. 526.51 N, P < .001) locations. Furthermore, 2 knots provided higher stiffness than 1 knot in both proximal (53.24 N/mm vs. 67.89 N/mm, P < .001) and distal (47.08 N/mm vs. 56.73 N/mm, P = .041) knot locations. However, using 2-0 suture showed no significant differences in failure load and stiffness regardless of knot location. Conclusion Using #2 suture and tying 2 independent knots across the CSB increased load to failure and stiffness compared to using only 1 knot regardless of knot position. Thus, if using #2 suture, it is recommended to tie 2 knots to enhance construct strength. However, with 2-0 suture, the number of knots did not impact construct strength. Therefore, if using 2-0 suture, 1 knot can be used to save time. Knot position did not significantly affect the strength or stiffness of the CSB construct, emphasizing the importance of considering knot prominence and surgical approach for determining knot location.
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Affiliation(s)
- John M. Apostolakos
- Steadman Philippon Research Institute, Vail, CO, USA
- The Steadman Clinic, Vail, CO, USA
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Kocazeybek E, Meric E, Ersin M, Ekinci M, Kizilkurt T, Sahinkaya T, Polat G. Clinical outcomes of three different techniques using adjustable-loop fixation in arthroscopic single-bundle anterior cruciate ligament reconstruction: A prospective randomized clinical trial. Knee 2023; 43:208-216. [PMID: 37467701 DOI: 10.1016/j.knee.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 06/14/2023] [Accepted: 06/30/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Adjustable femoral suspensory fixation for anterior cruciate ligament reconstruction (ACLR) become popular in recent years. The purpose of this study is to evaluate and compare the clinical outcomes of three different techniques using an adjustable-loop fixation in ACRL. METHODS This study included 38 patients who underwent ACLR using the adjustable-loop device for femoral fixation between January 2018 and November 2021. All the participants were randomly assigned to a standard (group 1), retensioning (group 2), retensioning and knot tying (group 3). Clinical outcome parametres included Tegner - Lysholm Score, IKDC score, KT-1000 displacement and isokinetic muscle function tests. RESULTS Overall, 38 patients (group 1: n = 13 [mean ± SD age, 30.1 ± 9.40 years]; group 2: n = 12 [mean ± SD age, 24.5 ± 7.79 years]; group 3 = 13 [mean ± SD age, 27.8 ± 6.59 years]) were included in the final analysis. The follow-up period was 9.7 ± 1.2; 9.5 ± 1.7 and 10 ± 1.5 months for groups 1, 2 and 3 respectively. From preoperatively to postoperatively, the mean Tegner-Lysholm scores improved significantly in all three groups (group 1: from 63.5 to 95.6; group 2: from 61.58 to 98.5; group 3: from 66.6 to 95.9, P < 0.0001 for all), as did the mean IKDC score (group 1: 53.9-88.8; group 2: 61.3-94.9; group 3: 60.7-94.6 (P < 0.0001 for all). CONCLUSION The retensioning with or without knot-tying method is believed to increase stability in graft fixation. However, there were no significant differences in clinical outcomes in each technique.
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Affiliation(s)
- Emre Kocazeybek
- Istanbul Faculty of Medicine, Department of Orthopedics and Traumatology, Istanbul University, İstanbul, Turkey.
| | - Emre Meric
- Istanbul Faculty of Medicine, Department of Orthopedics and Traumatology, Istanbul University, İstanbul, Turkey
| | - Mehmet Ersin
- Department of Orthopedics and Traumatology, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Mehmet Ekinci
- Department of Orthopedics and Traumatology, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Taha Kizilkurt
- Istanbul Faculty of Medicine, Department of Orthopedics and Traumatology, Istanbul University, İstanbul, Turkey
| | - Turker Sahinkaya
- Istanbul Faculty of Medicine, Department Sports Medicine, İstanbul, Turkey
| | - Gokhan Polat
- Istanbul Faculty of Medicine, Department of Orthopedics and Traumatology, Istanbul University, İstanbul, Turkey
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Additional tying on the adjustable-loop device improves the outcomes of anterior cruciate ligament reconstruction using hamstring autograft. Knee Surg Sports Traumatol Arthrosc 2022; 30:3673-3680. [PMID: 35445328 DOI: 10.1007/s00167-022-06936-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 03/07/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE The purpose of this study was to verify the efficacy of a novel technique for additional tying on the adjustable-loop device to prevent stress concentration on the graft loop end and gradual loop lengthening. METHODS A total of 124 patients who underwent anterior cruciate ligament reconstruction using hamstring autografts from 2014 to 2017 were included in this retrospective study. After 1:1 propensity score matching, two groups were formed (group I: 50 patients without tying vs. group II: 50 patients with tying). Anterior laxity was evaluated using side-to-side differences. Tunnel length, loop length, and graft-tunnel gap were measured using follow-up magnetic resonance imaging. The signal-to-noise ratio was calculated at the loop end, loop inner side, tunnel entrance, and graft mid-substance. The clinical outcomes were assessed using the International Knee Documentation Committee score, Lysholm score, pivot shift test, and Lachman test. RESULTS The average follow-up period was 63.2 ± 4.8 and 53.8 ± 11.9 months in groups I and II, respectively. Anterior laxity showed that side-to-side differences improved significantly 6 months postoperatively in both the groups. Although the anterior laxity improved in group II (2.9 ± 1.0 to 1.6 ± 0.8, p < 0.001), it deteriorated in group I (2.5 ± 1.5 to 3.3 ± 1.3 mm, p < 0.001) at the final follow-up. The graft-tunnel gap was significantly larger in group I (p < 0.001). The signal-to-noise ratios of the loop end and loop inner side were significantly higher in group I (p < 0.001 and p = 0.020, respectively). The clinical outcomes at the final follow-up were not significantly different between the groups. CONCLUSION The additional tying on the adjustable-loop device was not superior to the control group in clinical stability examination or outcome. However, it was effective in anterior laxity measured by stress radiographs, preventing stress on the adjustable-loop device, and gradual graft loop lengthening. LEVEL OF EVIDENCE Level III.
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Elmholt SB, Nielsen TG, Lind M. Fixed-loop vs. adjustable-loop cortical button devices for femoral fixation in ACL reconstruction - a systematic review and meta-analysis. J Exp Orthop 2022; 9:106. [PMID: 36269424 PMCID: PMC9587170 DOI: 10.1186/s40634-022-00544-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/12/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Simone Birkebæk Elmholt
- Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Torsten Grønbech Nielsen
- Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Martin Lind
- Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
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Adjustable-loop implants are non-inferior to fixed-loop implants for femoral fixation in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2022; 31:1723-1732. [PMID: 35737010 DOI: 10.1007/s00167-022-07034-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/30/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE Button implants with an adjustable-loop device (ALD) are often used in anterior cruciate ligament reconstruction (ACLR). Clinical research comparing ALDs with fixed-loop devices (FLD) has mainly been conducted in small patient populations with short follow-up times. To determine whether ALDs are safe to use in ACLR, a non-inferiority study with a large sample population and a long follow-up period would be beneficial. This study compared ALDs with FLDs to determine non-inferior revision surgery rates, knee stability, and patient-reported outcomes (PROM) in ACLRs. METHODS This non-inferiority register-based cohort study was conducted using data from the Danish Knee Ligament Reconstruction Registry (DKRR). A total of 12,723 patients > 15 years of age with primary ACLR using hamstring tendon autografts and either an FLD or ALD for femoral fixation were included: 9719 patients were in the FLD group, and 3014 patients were in the ALD group. The primary outcome was revision ACLR with a non-inferiority margin for ALDs at 4% at the 2-year follow-up. The secondary outcomes were anterior and rotatory knee stability and PROMs based on the Knee Injury and Osteoarthritis Outcome Score (KOOS) at the 1-year follow-up. RESULTS The crude cumulative revision rates in ALD implants at 2 and 5 years were 2.1% (95% CI 1.62-2.68) and 5.0% (95% CI 4.22-5.96), respectively. In the FLD group, the rates were 2.2% (95% CI 1.89-2.48) at 2 years and 4.7% (95% CI 4.31-5.20) at 5 years. The 1-year side-to-side differences were 0.97 mm (95% CI 0.90-1.03) in the ALD group and 1.45 mm (95% CI 1.41-1.49) in the FLD group. In the FLD group, 13% had a positive pivot shift, and in the ALD group, 6% had a positive pivot shift. There were no differences in KOOS. CONCLUSION ALDs were non-inferior to FLDs regarding revision rates, knee stability, and patient-reported outcomes. Based on this conclusion, ALDs are safe to use for femoral fixation in ACLR. LEVEL OF EVIDENCE III.
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Ammann E, Hecker A, Bachmann E, Snedeker JG, Fucentese SF. Evaluation of Tibial Fixation Devices for Quadrupled Hamstring ACL Reconstruction. Orthop J Sports Med 2022; 10:23259671221096107. [PMID: 35592018 PMCID: PMC9112421 DOI: 10.1177/23259671221096107] [Citation(s) in RCA: 6] [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: 02/18/2022] [Accepted: 02/25/2022] [Indexed: 11/26/2022] Open
Abstract
Background: Shortcomings to tibial-side fixation have been reported as causes of failure
after anterior cruciate ligament reconstruction. Adjustable-loop suspensory
devices have become popular; however, no comparison with hybrid fixation
(ie, interference screw and cortical button) exists to our knowledge. Purpose: The purpose of this study was to compare the biomechanical properties of
adjustable loop devices (ALDs) in full-tunnel and closed-socket
configurations in relation to hybrid fixation. We hypothesized that primary
stability of fixation by a tibial ALD will not be inferior to hybrid
fixation. Study Design: Controlled laboratory study. Methods: Tibial fixation of a quadrupled tendon graft was biomechanically investigated
in a porcine tibia–bovine tendon model using 5 techniques (n = 6 specimens
each). The tested constructs included hybrid fixation with a cortical
fixation button and interference screw (group 1), single cortical fixation
with the full-tunnel technique using an open-suture strand button (group 2)
or an ALD (group 3), or closed-socket fixation using 2 different types of
ALDs (groups 4 and 5). Each specimen was evaluated using a materials testing
machine (1000 cycles from 50-250 N and pull to failure). Force at failure,
cyclic displacement, stiffness, and ability to pretension the graft during
insertion were compared among the groups. Results: No differences in ultimate load to failure were found between the ALD
constructs (groups 3, 4, and 5) and hybrid fixation (group 1). Cyclic
displacement was significantly higher in group 2 vs all other groups
(P < .001); however, no difference was observed in
groups 3, 4, and 5 as compared with group 1. The remaining tension on the
construct after fixation was significantly higher in groups 3 and 4 vs
groups 1, 2, and 5 (P < .02 for all comparisons),
irrespective of whether a full-tunnel or closed-socket approach was
used. Conclusion: Tibial anterior cruciate ligament graft fixation with knotless ALDs achieved
comparable results with hybrid fixation in the full-tunnel and closed-socket
techniques. The retention of graft tension appears to be biomechanically
more relevant than tunnel type. Clinical Relevance: The study findings emphasize the importance of the tension at which fixation
is performed.
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Affiliation(s)
- Elias Ammann
- Balgrist University Hospital, Zürich, Switzerland
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Schützenberger S, Keller F, Grabner S, Kontic D, Schallmayer D, Komjati M, Fialka C. ACL reconstruction with femoral and tibial adjustable versus fixed-loop suspensory fixation: a retrospective cohort study. J Orthop Surg Res 2022; 17:244. [PMID: 35440030 PMCID: PMC9020032 DOI: 10.1186/s13018-022-03128-y] [Citation(s) in RCA: 5] [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: 01/31/2022] [Accepted: 04/06/2022] [Indexed: 11/10/2022] Open
Abstract
Background Cortical suspensory fixation (CSF) devices gain more and more popularity as a reliable alternative to interference screws for graft fixation in anterior cruciate ligament (ACL) reconstruction. Adjustable-loop fixation may be associated with increased anterior laxity and inferior clinical outcome. The purpose of the study was to compare anterior laxity and clinical outcome after minimally invasive all-inside ACL reconstruction using an adjustable-loop (AL) to a standard technique with a fixed-loop (FL) CSF device. Methods Patients who underwent primary single-bundle ACL reconstruction with a quadrupled hamstring autograft at a single institution between 2012 and 2016 were reviewed. In the AL group minimally invasive popliteal tendon harvesting was performed with an all-inside approach (femoral and tibial sockets). In the FL group a traditional anteromedial approach was used for tendon harvesting and a femoral socket and full tibial tunnel were drilled. An objective clinical assessment was performed with Telos x-rays and the International Knee Documentation Committee (IKDC) Objective Score. Patient-reported outcomes (PRO) included the IKDC Subjective Score, the Lysholm Knee Score, the Knee Injury and Osteoarthritis Score (KOOS) and the Tegner Activity Scale. Results A total of 67 patients were enrolled in this retrospective study with a mean follow-up of 4 (± 1.5) years. The groups were homogenous at baseline regarding age, gender, and the time to surgery. At follow-up, no statistically significant differences were found regarding anterior laxity (AL: 2.3 ± 3 mm vs. FL: 2.3 ± 2.6 mm, p = 0.981). PRO scores were comparable between the AL and FL groups (IKDC score, 84.8 vs. 88.8, p = 0.185; Lysholm 87.3 vs. 89.9, p = 0.380; KOOS 90.7 vs. 91.4, p = 0.720; Tegner 5.5 vs. 6.2, p = 0.085). The rate of saphenous nerve lesions was significantly lower in the AL group with popliteal harvesting of the tendon (8.3% vs. 35.5%, p = 0.014). Conclusion The use of an adjustable-loop device on the femoral and tibial side led to similar stability and clinical results compared to a fixed-loop device.
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Affiliation(s)
- Sebastian Schützenberger
- Department of Orthopaedic Surgery and Traumatology, AUVA Traumacenter Meidling, Kundratstrasse 37, 1120, Vienna, Austria.
| | - F Keller
- Department of Orthopaedic Surgery and Traumatology, AUVA Traumacenter Meidling, Kundratstrasse 37, 1120, Vienna, Austria
| | - S Grabner
- Department of Orthopaedic Surgery and Traumatology, AUVA Traumacenter Meidling, Kundratstrasse 37, 1120, Vienna, Austria
| | - D Kontic
- Department of Orthopaedic Surgery and Traumatology, AUVA Traumacenter Meidling, Kundratstrasse 37, 1120, Vienna, Austria
| | - D Schallmayer
- Department of Orthopaedic Surgery and Traumatology, AUVA Traumacenter Meidling, Kundratstrasse 37, 1120, Vienna, Austria
| | - M Komjati
- Department of Orthopaedic Surgery, Sacred Heart of Jesus Hospital, Vienna, Austria
| | - C Fialka
- Department of Orthopaedic Surgery and Traumatology, AUVA Traumacenter Meidling, Kundratstrasse 37, 1120, Vienna, Austria.,Department for Traumatology, Sigmund Freud Medical University, Vienna, Austria
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Takahashi T, Watanabe S, Ito T. Current and future of anterior cruciate ligament reconstruction techniques. World J Meta-Anal 2021; 9:411-437. [DOI: 10.13105/wjma.v9.i5.411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/09/2021] [Accepted: 10/25/2021] [Indexed: 02/06/2023] Open
Abstract
In recent years, anterior cruciate ligament (ACL) reconstruction has generally yielded favorable outcomes. However, ACL reconstruction has not provided satisfactory results in terms of the rate of returning to sports and prevention of osteoarthritis (OA) progression. In this paper, we outline current techniques for ACL reconstruction such as graft materials, double-bundle or single-bundle reconstruction, femoral tunnel drilling, all-inside technique, graft fixation, preservation of remnant, anterolateral ligament reconstruction, ACL repair, revision surgery, treatment for ACL injury with OA and problems, and discuss expected future trends. To enable many more orthopedic surgeons to achieve excellent ACL reconstruction outcomes with less invasive surgery, further studies aimed at improving surgical techniques are warranted. Further development of biological augmentation and robotic surgery technologies for ACL reconstruction is also required.
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Affiliation(s)
- Toshiaki Takahashi
- Department of Sports and Health Science, Ehime University, Matsuyama 790-8577, Ehime, Japan
| | - Seiji Watanabe
- Department of Orthopedic Surgery, Ehime University Graduate School of Medicine, Toon 791-0295, Ehime, Japan
| | - Toshio Ito
- Department of Orthopaedic Surgery, Murakami Memorial Hospital, Saijo 793-0030, Ehime, Japan
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Biomechanical Effects of Aspect Ratio of the Knee during Outside-In Anterior Cruciate Ligament Reconstruction Surgery. BIOMED RESEARCH INTERNATIONAL 2021; 2021:3454475. [PMID: 34527735 PMCID: PMC8437649 DOI: 10.1155/2021/3454475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/20/2021] [Indexed: 11/18/2022]
Abstract
We analyzed tunnel length, graft bending angle, and stress of the graft according to tunnel entry position and aspect ratio (ASR: ratio of anteroposterior depth to mediolateral width) of the articular surface for the distal femur during single-bundle outside-in anterior cruciate ligament reconstruction (ACLR) surgery. We performed multiflexible body dynamic analyses with four ASR (98, 105, 111, and 117%) knee models. The various ASRs were associated with approximately 1 mm changes in tunnel length. The graft bending angle increased when the entry point was far from the lateral epicondyle and was larger when the ASR was smaller. The graft was at maximum stress, 117% ASR, when the tunnel entry point was near the lateral epicondyle. The maximum stress value at a 5 mm distance from the lateral epicondyle was 3.5 times higher than the 15 mm entry position, and the cases set to 111% and 105% ASR showed 1.9 times higher stress values when at a 5 mm distance compared with a 15 mm distance. In the case set at 98% ASR, the low-stress value showed a without-distance difference from the lateral epicondyle. Our results suggest that there is no relationship between the ASR and femoral tunnel length. A smaller ASR causes a higher graft bending angle, and a larger ASR causes greater stress in the graft.
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Garcés GL, Martel O, Yánez A, Manchado-Herrera I, Motta LM. In Vitro Testing of 2 Adjustable-Loop Cortical Suspensory Fixation Systems Versus Interference Screw for Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2021; 9:23259671211031652. [PMID: 35146030 PMCID: PMC8821986 DOI: 10.1177/23259671211031652] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/24/2021] [Indexed: 11/23/2022] Open
Abstract
Background: It is not clear whether the mechanical strength of adjustable-loop suspension devices (ALDs) in anterior cruciate ligament (ACL) reconstruction is device dependent and if these constructs are different from those of an interference screw. Purpose: To compare the biomechanical differences of 2 types of ALDs versus an interference screw. Study Design: Controlled laboratory study. Methods: ACL reconstruction was performed on porcine femurs and bovine extensor tendons with 3 types of fixation devices: interference screw, UltraButton (UB) ALD, and TightRope (TR) ALD (n = 10 for each). In addition to specimen testing, isolated testing of the 2 ALDs was performed. The loading protocol consisted of 3 stages: preload (static 150 N load for 5 minutes), cyclic load (50-250 N at 1 Hz for 1000 cycles), and load to failure (crosshead speed 50 mm/min). Displacement at different cycles, ultimate failure load, yield load, stiffness, and failure mode were recorded. Results: In specimen testing, displacement of the ALDs at the 1000th cycle was similar (3.42 ± 1.34 mm for TR and 3.39 ± 0.92 mm for UB), but both were significantly lower than that of the interference screw (7.54 ± 3.18 mm) (P < .001 for both). The yield load of the UB (547 ± 173 N) was higher than that of the TR (420 ± 72 N) (P = .033) or the interference screw (386 ± 51 N; P = .013), with no significant difference between the latter 2. In isolated device testing, the ultimate failure load of the TR (862 ± 64 N) was significantly lower than that of the UB (1879 ± 126 N) (P < .001). Conclusion: Both ALDs showed significantly less displacement in cyclic loading at ultimate failure than the interference screw. The yield load of the UB was significantly higher than that of the other 2. The ultimate failure occurred at a significantly higher load for UB than it did for TR in isolated device testing. Clinical Relevance: Both UB and TR provided stronger fixation than an interference screw. Although difficult to assess, intrinsic differences in the mechanical properties of these ALDs may affect clinical outcomes.
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Affiliation(s)
- Gerardo L. Garcés
- Department of Medical and Surgical Sciences, University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Oscar Martel
- Department of Mechanical Engineering, University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Alejandro Yánez
- Department of Mechanical Engineering, University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | | | - Luci M. Motta
- University of Las Palmas de Gran Canaria, Las Palmas, Spain
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11
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Suspension button constructs restore posterior knee laxity in solid tibial avulsion of the posterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 2021; 29:4163-4171. [PMID: 33675369 PMCID: PMC8595177 DOI: 10.1007/s00167-021-06510-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 02/17/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Dislocated tibial avulsions of the posterior cruciate ligament (PCL) require surgical intervention. Several arthroscopic strategies are options to fix the fragment and restore posterior laxity, including two types of suspension button devices: adjustable (self-locking) and rigid knotted systems. Our hypothesis was that a rigid knotted button construct has superior biomechanical properties regarding laxity restoration compared with an adjustable system. Both techniques were compared with standard screw fixation and the native PCL. METHODS Sixty porcine knees were dissected. The constructs were tested for elongation, stiffness, yield force, load to failure force, and failure mode in a material testing machine. Group N (native, intact PCL) was used as a control group. In group DB (Dogbone™), TR (Tightrope™), and S (screw), a standardized block osteotomy with the osteotomized fragment attached to the PCL was set. The DB and TR groups simulated using a suspension button system with either a rigid knotted (DB) or adjustable system (TR). These groups were compared to a screw technique (S) simulating antegrade screw fixation from posterior. RESULTS Comparing the different techniques (DB, TR, S), no significant elongation was detected; all techniques achieved a sufficient posterior laxity restoration. Significant elongation in the DB and TR group was detected compared with the native PCL (N). In contrast, screw fixation did not lead to significant elongation. The stiffness, yield load, and load to failure force did not differ significantly between the techniques. None of the techniques reached the same level of yield load and load to failure force as the intact state. CONCLUSION Arthroscopic suspension button techniques sufficiently restore the posterior laxity and gain a comparable construct strength as an open antegrade screw fixation.
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Prado-Nóvoa M, Pérez-Blanca A, Espejo-Reina A, Lombardo-Torre M, Ezquerro-Juanco F, Espejo-Baena A. Assessment of fixation for anterior cruciate ligament reconstruction using oversized suspensory devices on full-length femoral tunnels. Clin Biomech (Bristol, Avon) 2020; 76:105008. [PMID: 32413774 DOI: 10.1016/j.clinbiomech.2020.105008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 02/13/2020] [Accepted: 03/27/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND In ACL repair, full-length single-diameter tunnels facilitate anatomic femoral fixation with suspensory devices, especially with outside-in techniques, and are required after accidental cortical perforation. With tunnel diameters over 6 mm, fixation resistance using regular suspensory devices may not suffice. Oversized cortical footprint devices could be a solution to guarantee fixation performance in larger tunnel diameters. This study aims to assess the biomechanical properties of ACL femoral fixation provided by two enlarged suspensory devices of similar characteristics, a fixed loop (G-Lok™ with G-Lok-XL™) and an adjustable loop (ProCinch™ with G-Lok-XL™), resting on a full-length 9 mm diameter tunnel compared to the widely accepted regular fixed-loop device (G-Lok™) on a socket tunnel. METHODS Twenty-seven fresh frozen porcine femurs and flexor digitorum profundus tendons were randomly assigned to a study group depending on the fixation method used (N = 9). Graft-femur constructs were subjected to a traction cyclic test (5000 cycles, [50-250]N load, 1 Hz) followed by a load-to-failure test (v = 1 mm/s). Residual displacement during the cyclic test and stiffness, displacements at physiological loads, ultimate load and corresponding displacement during the load-to-failure test were determined. FINDINGS No significant differences could be established for any parameter measured in the comparison between the control with the socket tunnel and the oversized fixations with full-length tunnels. INTERPRETATION ACL femoral fixation achieved in full-length single diameter tunnels by using an enlarged suspension device, both with a fixed or an adjustable loop, provide similar biomechanical properties to the gold-standard fixed-loop device in a socket tunnel. Therefore, its clinical use may be safe.
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Affiliation(s)
- María Prado-Nóvoa
- Escuela de Ingenierías Industriales, Laboratorio de Biomecánica, C/Dr. Ortíz Ramos s/n., 29071 Málaga, Spain
| | - Ana Pérez-Blanca
- Escuela de Ingenierías Industriales, Laboratorio de Biomecánica, C/Dr. Ortíz Ramos s/n., 29071 Málaga, Spain.
| | | | - Maximiano Lombardo-Torre
- Hospital Vithas Parque San Antonio, Avda Pintor Joaquin Sorolla, 2, 29016 Malaga, Spain; Hospital Universitario Virgen de la Victoria, Servicio de Traumatología y Cirugía Ortopédica, Campus de Teatinos s/n., 29010 Málaga, Spain
| | - Francisco Ezquerro-Juanco
- Escuela de Ingenierías Industriales, Laboratorio de Biomecánica, C/Dr. Ortíz Ramos s/n., 29071 Málaga, Spain
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Singh S, Ramos-Pascual S, Czerbak K, Malik M, Schranz PJ, Miles AW, Mandalia V. Biomechanical testing of fixed and adjustable femoral cortical suspension devices for ACL reconstruction under high loads and extended cyclic loading. J Exp Orthop 2020; 7:27. [PMID: 32394303 PMCID: PMC7214603 DOI: 10.1186/s40634-020-00235-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 03/23/2020] [Indexed: 01/12/2023] Open
Abstract
Purpose To compare loop elongation after 5000 cycles, loop-elongation at failure, and load at failure of the fixed-loop G-Lok device and three adjustable-loop devices (UltraButton, RigidLoop Adjustable and ProCinch RT), during testing over extended cycles under high loading. Methods Five devices of each type were tested on a custom-built rig fixed to an Instron machine. The testing protocol had four stages: preloading, cyclic preconditioning, incremental cyclic loading and pull-to-failure. Outcome measures were loop elongation after 5000 cycles, loop-elongation at failure, and load at failure. Results The loop elongation after 5000 cycles for G-Lok was 1.46 ± 0.25 mm, which was comparable to that of RigidLoop (1.51 ± 0.16 mm, p = 1.000) and ProCinch (1.60 ± 0.09 mm, p = 1.000). In comparison, the loop elongation for UltraButton was 2.66 ± 0.28 mm, which was significantly larger than all other devices (p = 0.048). The failure load for all devices ranged between 1455 and 2178 N. G-Lok was significantly stronger than all adjustable-loop devices (p = 0.048). The elongation at failure was largest for UltraButton (4.20 ± 0.33 mm), which was significantly greater than G-Lok (3.17 ± 0.33 mm, p = 0.048), RigidLoop (2.88 ± 0.20 mm, p = 0.048) and ProCinch (2.78 ± 0.08 mm, p = 0.048). There was no significant difference in elongation at failure for the rest of the devices. Conclusions Our study has shown that the G-Lok fixed-loop device and the three adjustable-loop devices (UltraButton, RigidLoop Adjustable and ProCinch RT) all elongated less than 3 mm during testing over an extended number of cycles at high loads, nonetheless, the fixed loop device performed best in terms of least elongation and highest load at failure.
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Affiliation(s)
- Sarvpreet Singh
- Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, UK
| | - Sonia Ramos-Pascual
- Centre for Orthopaedic Biomechanics, Department of Mechanical Engineering, University of Bath, Bath, UK.
| | - Kinga Czerbak
- Centre for Orthopaedic Biomechanics, Department of Mechanical Engineering, University of Bath, Bath, UK
| | - Muzaffar Malik
- Division of Medical Education, Brighton and Sussex Medical School, University of Brighton, BN1 9PH, Brighton, UK
| | - Peter J Schranz
- Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, UK
| | - Anthony W Miles
- Centre for Orthopaedic Biomechanics, Department of Mechanical Engineering, University of Bath, Bath, UK
| | - Vipul Mandalia
- Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, UK
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Takahashi T, Takahashi M. The improved cortical button shows better breaking strength of sutures compared with 10 original cortical button after cyclic loading. J Exp Orthop 2020; 7:17. [PMID: 32222847 PMCID: PMC7103022 DOI: 10.1186/s40634-020-00232-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/10/2020] [Indexed: 01/01/2023] Open
Abstract
Background Suspensory cortical buttons are widely used for fixation of reconstructed ligaments during anterior cruciate ligament (ACL) reconstruction because they have high usability and a favorable fixing force. However, it is not always easy to fix a reconstructed ACL while maintaining appropriate ligament tension. Therefore, we developed an improved cortical button that provides temporary tension until suturing is completed. Methods Button holes of our improved EndoButton are not perpendicular to the bone surface on which the button is placed, but have an angle of 45 degrees so that the button can be temporarily fixed by applying tension to the suture. The improved EndoButton and the original EndoButton (Smith & Nephew Inc., Andover, Massachusetts) were each tied to FiberWire 5/7 metric (5 M) (manufactured by Arthrex). Ten cycles of preliminary loading (0–50 N) were applied to each suture, followed by test loading (0–250 N) for 500 or 1000 cycles. Then, a tensile test was performed at a displacement velocity of 20 mm/min. Results The breaking strength of the sutures of the improved EndoButton were tend to higher than those of the sutures of the original EndoButton after 1000 loading cycles (p = 0.067, d = 0.883). The moduli of rigidity of the sutures of the improved EndoButton were higher than those of the sutures of the original EndoButton after 500 loading cycles (p = 0.027) and remained almost the same regardless of the number of loading cycles. Conclusion We found that compared with the original cortical button, the improved cortical button was better able to retain suture breaking strength and modulus of rigidity, regardless of the number of load cycles.
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Affiliation(s)
- Toshiaki Takahashi
- Department of Sports and Health Science, Faculty of Collaborative Regional Innovation, Ehime University, 3 Bunkyo-cho, Matsuyama, Ehime, 790-8577, Japan.
| | - Manabu Takahashi
- Department of Industrial Innovation, Faculty of Collaborative Regional Innovation, Ehime University, 3 Bunkyo-cho, Matsuyama, Ehime, 790-8577, Japan
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Singh S, Shaunak S, Shaw SCK, Anderson JL, Mandalia V. Adjustable Loop Femoral Cortical Suspension Devices for Anterior Cruciate Ligament Reconstruction: A Systematic Review. Indian J Orthop 2020; 54:426-443. [PMID: 32549958 PMCID: PMC7270319 DOI: 10.1007/s43465-019-00022-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/19/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) injury is a common sports injury. Symptomatic knee instability after this injury is usually treated operatively through ACL reconstruction. The surgery involves a tendon graft being fixed in bony tunnels drilled through femur and tibia. The fixation of the graft is of critical importance to achieving good results. One of the commonest devices used to fix the graft in the femoral bony tunnel is a fixed loop cortical suspensory device. More recently, adjustable loop cortical suspension devices have been introduced, and have gained popularity for ACL reconstruction. These allow for adjusting the length of the suspension loop after insertion. There is currently much debate concerning whether the adjustable loop devices are superior or inferior to the fixed loop devices. PURPOSE To critique and review the current biomechanical and clinical evidence on the use of adjustable loop devices in hamstring ACL reconstruction. To our knowledge, there have been no previous reviews of this topic. STUDY DESIGN Systematic review. METHODS This systematic review was conducted in accordance with PRISMA. Five databases were searched using multiple search terms and MeSH terms where possible. The following limits were applied: papers published in English and papers published in the last 21 years. RESULTS Eleven laboratory and six clinical studies were reviewed. The laboratory-based studies have frequently shown elongation of adjustable loop devices to more than 3 mm under loading protocols, whereas the clinical studies have not shown any significant differences between the patients with fixed loop and the ones with adjustable loop devices. CLINICAL SIGNIFICANCE This review shows a discrepancy between laboratory-based and clinical studies. The review of clinical studies in our paper would give future researchers confidence and act as a prompt to construct randomised clinical trials to investigate these devices further. CONCLUSION We feel that more robust clinical randomised studies and trials are needed to evaluate these new devices.
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Affiliation(s)
- Sarvpreet Singh
- Department of Trauma and Orthopaedics, North West Anglia NHS Foundation Trust, Cambridgeshire, UK
| | | | - Sebastian C. K. Shaw
- Department of Medical Education, Brighton and Sussex Medical School, Brighton, East Sussex UK
| | | | - Vipul Mandalia
- Western Sussex Hospitals NHS Foundation Trust, West Sussex, UK
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Snaebjörnsson T, Hamrin-Senorski E, Svantesson E, Karlsson L, Engebretsen L, Karlsson J, Samuelsson K. Graft Diameter and Graft Type as Predictors of Anterior Cruciate Ligament Revision: A Cohort Study Including 18,425 Patients from the Swedish and Norwegian National Knee Ligament Registries. J Bone Joint Surg Am 2019; 101:1812-1820. [PMID: 31626005 DOI: 10.2106/jbjs.18.01467] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND It is important to investigate and compare graft diameters as well as graft types to identify risk factors for revision after an anterior cruciate ligament (ACL) reconstruction. We performed the current study in order to analyze the early ACL revision rate among patients treated with hamstring tendon (HT) autografts or patellar tendon (PT) autografts of different diameters. Our hypothesis was that an increase in both HT and PT autograft diameters would reduce the risk of early ACL revision. METHODS This retrospective study was based on prospectively collected data from the national knee ligament registries of Norway and Sweden and included patients who underwent primary ACL reconstruction during the period of 2004 through 2014. The primary end point was the 2-year incidence of ACL revision. The impact of graft type and diameter on the incidence of revision surgery was reported as relative risks (RRs) with 95% confidence intervals (CIs), estimated by using generalized linear models with a binomial distribution and log-link function. RESULTS Of 58,692 patients identified, a total of 18,425 patients were included in this study. The 2-year rate of ACL revision was 2.10% (PT autografts, 2.63%; HT autografts, 2.08%; RR = 0.93 [95% CI = 0.60 to 1.45]). There was an increased risk of ACL revision among patients treated with HT autografts with a diameter of <8 mm compared with larger HT autografts (RR = 1.25 [95% CI = 1.01 to 1.57]). Patients treated with HT autografts with a diameter of ≥9.0 mm or ≥10.0 mm had a reduced risk of early ACL revision compared with patients treated with PT autografts. CONCLUSIONS Patients treated with larger-diameter HT autografts had a lower risk of early ACL revision compared with those treated with HT autografts of <8 mm. Patients treated with HT autografts of ≥9 or ≥10 mm had a reduced risk of early ACL revision compared with patients treated with PT autografts. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Thorkell Snaebjörnsson
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Eric Hamrin-Senorski
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eleonor Svantesson
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Louise Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Jon Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
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Forkel P, Imhoff AB, Achtnich A, Willinger L. [All-arthroscopic fixation of tibial posterior cruciate ligament avulsion fractures with a suture-button technique]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2019; 32:236-247. [PMID: 31492968 DOI: 10.1007/s00064-019-00626-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/23/2019] [Accepted: 04/25/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To restore the posterior stability of the knee after a tibial posterior cruciate ligament (PCL) avulsion with a suture-button construct. INDICATIONS Acute solid and monofragment bony avulsion of the tibial PCL insertion. CONTRAINDICATIONS Chronic condition of avulsion fractures or posterior instability, multifragment avulsions, thin bone pieces, advanced knee osteoarthritis, high-grade soft tissue injury, infection. SURGICAL TECHNIQUE Supine position, all-arthroscopic treatment via posteromedial and posterolateral portal, arthroscopic visualization and fracture reduction, transtibial drilling with a cannulated 2.4 mm drill, reduction of the fragment via FiberTape™ and Dog Bone. Knotting of the tapes against an additional Dog Bone at the anterior aspect of the tibia. Intraoperative x‑ray. POSTOPERATIVE MANAGEMENT Knee extension brace with posterior tibial support for 6 weeks, 20 kg partial weight-bearing and restricted flexion up to 90° for 6 weeks, physiotherapy in prone position from the first postoperative day. Full weight bearing after x‑ray and clinical control after 6 weeks. RESULTS Since 2016 eight tibial PCL avulsions were treated. In 6 patients a suture-bridge technique via a mini-open approach was performed due to a small or comminuted fracture fragment. In 2 patients an all-arthroscopic technique was performed. No complications. The all-arthroscopic technique requires a solid fragment and enables the surgeon to treat additional pathologies. In general, the arthroscopic technique makes the open posterior approach unnecessary. The arthroscopic techniques achieve slightly higher objective and subjective values compared to the open procedure, despite a higher rate of arthrofibrosis.
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Affiliation(s)
- Philipp Forkel
- Abteilung für Sportorthopädie, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Deutschland.
| | - Andreas B Imhoff
- Abteilung für Sportorthopädie, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - Andrea Achtnich
- Abteilung für Sportorthopädie, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - Lukas Willinger
- Abteilung für Sportorthopädie, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Deutschland
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Onggo JR, Nambiar M, Pai V. Fixed- Versus Adjustable-Loop Devices for Femoral Fixation in Anterior Cruciate Ligament Reconstruction: A Systematic Review. Arthroscopy 2019; 35:2484-2498. [PMID: 31147109 DOI: 10.1016/j.arthro.2019.02.029] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 02/12/2019] [Accepted: 02/17/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare biomechanical and clinical outcomes between adjustable-loop devices (ALDs) and fixed-loop devices (FLDs) in the femoral fixation component of anterior cruciate ligament reconstruction (ACLR) using a hamstring autograft or allograft. METHODS A multi-database search was performed on July 18, 2018, according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. All articles directly comparing ALDs and FLDs in ACLR using hamstring grafts were included. Non-English-language articles were excluded. RESULTS We included 13 biomechanical, 2 prospective, and 6 retrospective studies in this review. Retensioning of ALDs was performed in 4 of 13 biomechanical studies and in all clinical studies. Biomechanically, 11 studies showed a statistically significantly larger maximum irreversible displacement of the graft in the ALD group. Two studies showed no statistically significant difference with retensioning of the TightRope ALD, whereas all 3 studies that examined knotting of ALDs showed no statistically significant difference between the FLD and ALD groups. Five studies reported statistically significantly higher graft stiffness for FLDs than ALDs. Retensioning or knotting did not produce any significant change in construct stiffness. Nine studies reported a statistically significantly higher ultimate load to failure for FLDs. With knotting of ALDs, this difference was no longer statistically significant in only 1 study. Clinical studies showed no statistically significant differences in clinical, functional, radiologic, and complication outcomes between both groups. CONCLUSIONS Despite the superior biomechanical properties of FLDs, ALDs and FLDs yielded similar clinical outcome scores and graft rerupture rates. Biomechanical outcomes were improved with retensioning of ALDs after tibial fixation, as per manufacturer recommendations. LEVEL OF EVIDENCE Level III, systematic review of Level III and IV studies.
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Houck DA, Kraeutler MJ, McCarty EC, Bravman JT. Systematic Review of Fixed- Versus Adjustable-Loop Femoral Cortical Suspension Devices for Anterior Cruciate Ligament Reconstruction: Response. Orthop J Sports Med 2019; 7:2325967119843505. [PMID: 31334705 PMCID: PMC6545660 DOI: 10.1177/2325967119843505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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Shang X, Li J, Li Q. Systematic Review of Fixed- Versus Adjustable-Loop Femoral Cortical Suspension Devices for Anterior Cruciate Ligament Reconstruction: Letter to the Editor. Orthop J Sports Med 2019; 7:2325967119843504. [PMID: 31211148 PMCID: PMC6545666 DOI: 10.1177/2325967119843504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Supplemental Fixation of Inner Graft Limbs in All-Inside, Quadrupled, Single-Tendon Anterior Cruciate Ligament Reconstruction Graft Construct Yields Improved Biomechanical Properties. Arthroscopy 2019; 35:909-918. [PMID: 30736995 DOI: 10.1016/j.arthro.2018.10.130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 10/26/2018] [Accepted: 10/26/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the time-zero load to failure of a quadrupled, single-tendon, all-inside anterior cruciate ligament (ACL) reconstruction graft construct with (supplemented) and without the incorporation of inner-limb whipstitch sutures (control) into a tibial suspensory fixation button. METHODS Eight matched pairs of peroneus longus tendons were prepared according to a quadrupled, all-inside ACL soft-tissue graft technique with 1 side serving as a control and the contralateral side supplemented. The constructs were biomechanically tested for strain in the inner and outer limbs during a preconditioning protocol, single-cycle load to failure, and elongation of the whole construct. RESULTS Ultimate load to failure was significantly higher in the supplemented group: 797.5 ± 49.6 N (95% confidence interval [CI], 763.13-831.87 N) versus 719.6 ± 69.6 N (95% CI, 671.38-767.82 N; P = .044). Less graft elongation at failure was observed in the supplemented group (3.1 ± 1.5 mm; 95% CI, 2.07-4.17 mm) versus the control group (21.0 ± 21.2 mm; 95% CI, 6.31-35.69 mm; P = .052). The number of grafts undergoing a 5-mm or greater change in length at failure was 1 of 8 in the supplemented group versus 5 of 8 in the control group (P = .038). CONCLUSIONS Inner-limb supplemental tibial fixation results in higher time-zero load to failure and decreased graft elongation in a quadrupled, single-tendon, all-inside ACL reconstruction graft construct. CLINICAL RELEVANCE The weak point of a single-tendon, quadrupled, all-inside ACL graft construct is the tendon-to-tendon suturing to secure the inner limbs of the graft. Adding supplemental fixation by incorporating the sutures from the inner limb to the tibial suspensory fixation button leads to a higher time-zero load to failure and decreased graft elongation.
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