Primary Anterior Cruciate Ligament Repair Using Suture Tape Augmentation: A Case Series of 29 Patients With Minimum 2-Year Follow-Up

Anterior Cruciate Ligament Repair With Suture Tape Augmentation of Proximal Tears and Early Anterior Cruciate Ligament Reconstruction With Suture Tape Augmentation Result in Comparable Clinical Outcomes With Anterior Cruciate Ligament Reconstruction at 2-Year Follow-Up

PURPOSE

To compare the postoperative side-to-side laxity and short-term clinical outcomes of patients who received primary anterior cruciate ligament (ACL) repair with suture tape augmentation, acute anterior cruciate ligament reconstruction (ACLR) with suture tape augmentation performed within 8 weeks of injury (ACLRacute), or ACLR beyond 8 weeks of injury.

METHODS

After institutional review board approval was obtained, 100 patients were enrolled in this prospective trial: 34 primary ACL repair with suture tape augmentation, 33 ACLRs performed within 8 weeks of injury (ACLRacute), and 33 ACLRs. Patients were allocated to ACL repair if a proximal avulsion was present with good tissue quality (Sherman type 1), confirmed by intraoperative diagnostic arthroscopy. Preoperative side-to-side anteroposterior knee laxity was assessed with KT-1000 arthrometer, and patient-reported outcomes (PROs) including the visual analog scale, Marx activity scale, Veterans RAND 12-item health survey (VR-12 physical & mental), Single Assessment Numeric Evaluation, Knee Injury and Osteoarthritis Outcome Score survey subscales, and range of motion were collected. These objective and subjective measures were repeated at regular intervals postoperatively through 2 years. Minimal clinically important difference calculations were performed assessing postoperative PRO changes at 2 years compared with preoperative.

RESULTS

The average time from injury to surgery was 5.03 ± 1.2 weeks for the ACL repair group, 5.09 ± 0.74 weeks for the ACLRacute, and 43.22 ± 33.5 weeks for the ACLR group. Postoperatively, the KT-1000 side-to-side laxity difference for 30 lbs was determined to be 0.1 ± 0.37 (95% confidence interval [CI] -0.7 to 0.8) for ACL repair versus ACLR (P < .0001), -0.8 ± 0.35 (95% CI -1.5 to -0.1) for ACLRacute versus ACLR (P < .0001), and 0.8 ± 0.40 (95% CI 0.0-1.6) for ACL repair versus ACLRacute (P < .0001). The data reveal ACL repair and ACLRacute are noninferior to ACLR at 2-year follow-up. The postoperative difference from baseline for all PROs demonstrated improvement for all PROs. Magnetic resonance imaging at 1 year revealed tissue healing for the 3 ACL injury treatment groups.

CONCLUSIONS

Patients who underwent ACL repair of proximal tears with suture tape augmentation or ACL reconstruction within 8 weeks from injury resulted in noninferior side-to-side knee laxity, comparable PROs, and similar range of motion at 2-year follow-up compared with ACLR.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Anterior Cruciate Ligament Repair Leads to Improved Patient-Reported Outcomes Compared to Anterior Cruciate Ligament Reconstruction

Introduction Anterior cruciate ligament (ACL) tears occur frequently in young athletes, and ligament repair and reconstruction are surgical treatments. Although there are suggested benefits for both approaches, there is a lack of direct comparisons between ACL repair and reconstruction.This study aims to compare the mid-term functional outcomes and quality of life measures between patients that have undergone ACL repair versus reconstruction. Methods A retrospective review was conducted for demographic and operative report data of patients who underwent an ACL repair or reconstruction between 2012 and 2018. Patients were contacted over the phone and underwent a Patient-Reported Outcomes Measurement Information System (PROMIS) survey evaluating pain interference, mobility, and function. Patients were excluded from the study if there was an incomplete operative note, missing contact information, or failure to answer phone calls. Results A total of 74 eligible patients were included, with n = 54 in the ACL reconstruction group (73.0%) and n = 20 in the ACL repair group (27.0%). Reconstruction patients had a PROMIS (median (IQR)) physical function score of 22.50 (16.00-59.00), as compared to repair patients' physical function score of 60.00 (21.50-60.00). There was a significant difference favoring repair (p = 0.040). In addition, ACL reconstruction patients had a significantly higher rate of additional procedures, with 63.0% of reconstruction patients receiving an additional operation as compared to 30.0% of repair patients (p = 0.017). The surgery type did not show a significant effect on physical function scores, while additional procedures remained significant in the linear regression analysis. Conclusion Although ACL repair is associated with improved physical function scores as compared to reconstruction in the univariate analysis, surgery type did not show significance when controlling for other variables. Further studies are necessary to compare patients with similar injuries to account for differences in additional procedures, but the results remain promising in assisting with patient-driven treatment decisions.

Outcomes of Primary Anterior Cruciate Ligament (ACL) Repair for Proximal Tears: A Systematic Review and Meta-Analysis

The purpose of this study is to compare failure rates among different techniques of primary anterior cruciate ligament (ACL) repair for the treatment of proximal ACL ruptures. Meta-analysis and systematic review were completed, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Studies from Embase, Cochrane, and PubMed published between June 2011 and June 2022 reporting outcomes of primary ACL repair on proximal tears with a minimum two-year follow-up were included. Primary ACL repair was divided into dynamic, static, and non-augmented repair. The primary outcome was failure rates, and the secondary outcomes included patient-reported outcomes (PROs) and anterior tibial stability (ATT). Eighteen studies on primary ACL repair were included, with a total of 614 patients (ages ranging from 6 to 65, 60% male). Only two studies were level 1 randomized controlled clinical trials. The static repair had a failure rate of 33 out of 261 (12.6%), non-augmented was 17 out of 179 (9.4%), and dynamic repair was 31 out of 174 (17.8%); no statistically significant difference was found comparing the failure rates (p = 0.090). PROs using the International Knee Documentation Committee (IKDC) and Lysholm scores had weighted averages of 91.7 (95% confidence interval (CI): 89.6-93.8) and 94.7 (95% CI: 92.7-96.7), respectively. ATT had a weighted average of 1.668 mm (95% CI: 1.002-2.334). The primary findings of this paper include a 12.6% combined failure rate for primary proximal ACL repair with no significant difference in failure rate or PROs when accounting for the methodology of repair at a minimum two-year follow-up. It is important to note the lack of high-quality randomized controlled trials, the heterogeneity of included studies, and the lack of long-term data. Despite these limitations, the findings of the current analysis suggest that primary repair may be a useful treatment option for indicated candidates with proximal ACL ruptures. Further long-term and higher-quality comparative studies on ACL reconstruction are warranted.

Suture Anchor Technique for Bridge Enhanced Anterior Cruciate Ligament Restoration

Anterior cruciate ligament (ACL) injuries are common in the athletic population. ACL repair with bridge enhancement is an emerging technology with promising clinical outcomes in patients with a proximal to midsubstance ACL tears. Currently, there are a variety of fixation methods described for isolated ACL repair, including suspensory and anchor techniques. This Technical Note describes a bridge enhanced ACL restoration procedure technique, using suture anchors for the femoral fixation. Advantages of this technique include more rigid fixation and avoiding need for accessory over-the-top incision. Additionally, the surgical workflow is more similar to an ACL reconstruction with intra-articular screw fixation, which may be more readily adopted by some surgeons.

Suture-Augmented Anterior Cruciate Ligament Repair for Proximal Avulsion or High-Grade Partial Tears Shows Similar Side-to-Side Difference and No Clinical Differences at Two Years Versus Conventional Anterior Cruciate Ligament Reconstruction for Mid-Substance Tears or Poor Anterior Cruciate Ligament Tissue Quality

PURPOSE

To compare objective and subjective clinical outcomes between suture-augmented anterior cruciate ligament (ACL) repair (SAACLR) and conventional ACL reconstruction (CACLR) with minimum 2-year follow-up.

METHODS

In this nonrandomized, prospective study, 30 patients underwent SAACLR for proximal ACL avulsion or high-grade partial ACL tear (Sherman grade 1 or 2) and 30 patients underwent CACLR for proximal one-third/distal two-thirds junction tears and mid-substance tears (Sherman grade 3 or 4) tear types by 1 surgeon between 2018 and 2020. Failure was defined as ACL reinjury. Outcome measures were KT-1000 for side-to-side knee laxity evaluation, Visual Analog Scale for pain, International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Severity Score (KOOS), Tegner Activity Scale, Western Ontario and McMaster Universities Osteoarthritis Index, Lysholm Knee Scoring Scale, and Single Assessment Numeric Evaluation. Minimal clinically important difference (MCID) was calculated for IKDC and KOOS subscores.

RESULTS

Three failures (10%) occurred in the SAACLR group, with no failures in the CACLR group (P = .24). A total of 23 (85%) SAACLR patients and 27 (90%) CACLR patients had patient-reported outcomes and physical examination at minimum 2 years. Two-year KT-1000 testing with 20 lbs showed less than 1 mm side-to-side difference between the groups. No significant differences in the percentage of patients meeting the MCID were found between the SAACLR and CACLR groups at 2 years: IKDC, 10.81 (82%) versus 10.54 (93%) (P = .48); KOOS Pain, 11.55 (73%) versus 10.58 (78%) (P = .94); KOOS Symptoms, 8.15 (77%) versus 10.32 (74%) (P = 1.0); KOOS Activities of Daily Living, 12.19 (59%) versus 12.28 (70%) (P = .60); 18.99 (71%) versus 16.77 (86%) (P = .42). Significantly higher IKDC scores were observed with SAACLR versus CACLR at 3 months (P = .01) and 6 months (P = .02), and significantly higher Lysholm scale, Tegner Activity Scale, and all KOOS subscale scores were observed at 6 months.

CONCLUSIONS

At 2 years after surgery, KT-1000 testing showed less than 1 mm side-to-side difference and no differences were observed between the groups in the percentage of patients who met or exceeded the MCID. Significantly higher early patient-reported outcome scores were found with SAACLR versus CACLR. The rerupture rate between the groups was not significantly different.

LEVEL OF EVIDENCE

Level II, Prospective cohort study.

Comparison of Clinical Outcomes Between Modern Augmented ACL Repair and Autograft ACL Reconstruction: A Systematic Review and Meta-analysis of Studies With Minimum 2-Year Follow-up

Background

Anterior cruciate ligament (ACL) reconstruction has been the gold standard for primary ACL rupture since the 1990s. In the past decade, ACL repair has received renewed attention and increased research.

Purpose

To compare the clinical outcomes of modern augmented ACL repair versus autograft reconstruction for ACL ruptures.

Study Design

Systematic review; Level of evidence, 3.

Methods

A search of the PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Library databases was conducted for prospective or retrospective comparative studies published between January 1, 2010, and January 3, 2023, with a minimum 2-year follow-up. Two independent reviewers performed data extraction and methodological quality assessment. Sensitivity analysis was performed to maintain the stability of results.

Results

Nine studies were included (minimum follow-up period, 24-60 months). The total sample size was 833 patients (augmented repair group: 358 patients; autograft ACL reconstruction group: 475 patients). There were 4 randomized controlled trials (level 1), 1 prospective comparative study (level 2), 2 retrospective comparative studies (level 3), and 2 case-control studies (level 3). The augmented ACL repair group attained significantly higher Lysholm score (weighted mean difference [WMD] = 1.57; 95% confidence interval [CI], 0.14-3.01; P = .03) and hamstring strength (WMD = 36.69; 95% CI, 29.07-44.31; P < .01) but had higher rates of hardware removal (odds ratio [OR] = 6.30; 95% CI, 2.44-16.23; P = .0001), reoperation (OR = 1.87; 95% CI, 1.33-2.62; P = .0003), and failure (OR = 1.58; 95% CI, 1.03-2.43; P = .0003) compared with the autograft ACL reconstruction group. No significant differences were observed between the repair and reconstruction groups regarding postoperative International Knee Documentation Committee scores, Tegner scores, knee laxity, satisfaction, ACL revisions, complications, and reoperation rather than revision.

Conclusion

Augmented ACL repair was associated with higher rates of reoperation, hardware removal, and failure compared with autograft ACL reconstruction in studies with minimum 2-year follow-up data. However, augmented ACL repair had higher Lysholm scores and hamstring strength versus autograft ACL reconstruction.

Various Definitions of Failure Are Used in Studies of Patients Who Underwent Anterior Cruciate Ligament Reconstruction

Purpose

To conduct a literature review to assess the definitions of anterior cruciate ligament reconstruction (ACLR) failure used throughout the orthopaedic literature.

Methods

A systematic search of Embase, Ovid Medline, SPORTDiscus, and Web of Science was conducted by a university librarian to identity level I-IV clinical studies on ACLR failure. Inclusion criteria consisted of patients who underwent ACLR and included a definition of failure of ACLR. Patients who underwent anterior cruciate ligament (ACL) repairs, animal/cadaver studies, review studies, non-English language articles, and non-full text articles were excluded. Failure data were extracted from each study and categorized. Other data that were extracted included follow-up time after ACLR, failure reoperation rate, and failure reoperation procedure. Descriptive statistics was used to analyze the data.

Results

Out of 2,775 studies, 104 (3.75%) met inclusion criteria and were analyzed in this review. The most common definition of ACLR failure included the use of a physical examination, specifically Lachman's test (21/104 [20.2%]), anterior laxity assessment, or a Pivot-Shift test (24/104 [35.2%]) or undergoing or requiring revision ACLR (39/104 [37.5%]). Although some studies used quantitative tests or imaging to help define "failure," others simply defined it as graft rerupture that was otherwise not defined (22/104 [22.5%]). Other common definitions included: the use of imaging (magnetic resonance imaging/radiographs) to confirm graft re-rupture (37/104 [35.6%]), patient-reported outcomes (recurrent instability)/patient reported outcomes measures (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Tegner) (18/104 [17.3%]), and the use of an arthrometer (KT-1000/2000, Rollimeter, or Kneelax) (17/104 [16.3%]). The least common definitions included graft failure or rerupture confirmed by arthroscopy (13/104 [12.5%]) and nonrevision surgery (2/104 [1.0%]). The failure rate of this procedure ranged from 0% to 100% depending on the definition of "failure."

Conclusion

In this study, we found that a variety of definitions of failure are used among studies published in the orthopaedic literature. The most common criteria for failure of ACLR were the results of physical examination tests (35%), the need for undergoing a revision ACLR (36%), and the use of imaging to diagnose the failure (34%). About 17% of studies included in this review used patient-reported outcomes, specifically recurrent instability, or PROMs (IKDC, KOOS, Tegner) in their assessment of failure of ACLR. The least used definitions of "failure" of ACLR included nonrevision ACLR surgery (2%). Although some studies used similar tests or categories in their definition of failure, there were a variety of score and grade cutoff points between them.

Level of Evidence

Level IV, systematic review of Level II-IV studies.

Favorable Patient-Reported, Clinical, and Functional Outcomes 2 Years After ACL Repair and InternalBrace Augmentation Compared With ACL Reconstruction and Healthy Controls

BACKGROUND

Recently, interest in anterior cruciate ligament (ACL) preservation and repair after proximal ACL tears has been resurrected. Although good clinical outcomes have been reported in the literature with adequate patient selection, to date detailed scientific evidence for the functional benefit of primary ACL repair with ligament augmentation is scarce.

PURPOSE

To compare patient-reported, clinical, and functional outcomes in patients 2 years after ACL repair and InternalBrace augmentation (ACL-IB) with age- and sex-matched patients 2 years after ACL reconstruction (ACL-R) and with matched healthy controls.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

In total, 29 patients 2 years after ACL-IB, 27 sex- and age- matched patients 2 years after ACL-R (hamstring autografts), and 29 matched healthy controls were included. Patient-reported outcomes were assessed using the International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, EQ-5D-5L, Tegner Activity Scale, and Anterior Cruciate Ligament Return to Sports after Injury scale. Surgery time was recorded. For clinical outcomes, range of motion and thigh and shank circumference were measured, and passive anterior translation was determined using the Rolimeter. Isokinetic muscle strength was measured using a Biodex dynamometer. The limb symmetry index (operated/contralateral or nondominant/dominant × 100), side-to-side differences (operated - contralateral, nondominant - dominant), and hamstring-quadriceps ratios were calculated for functional parameters. Failure and reoperation rates were not compared.

RESULTS

Two years after surgery, patients treated with ACL-IB showed good to excellent patient-reported outcomes comparable with those of patients after ACL-R. Surgery time, including concomitant surgeries, was significantly shorter in the ACL-IB group (mean, 81 minutes) compared with the ACL-R group (mean, 97 minutes) (P = .024). Isokinetic muscle strength was comparable between patient groups without significant differences in extensor and flexor strength or in hamstring-quadriceps ratios.

CONCLUSION

These results suggest that ACL-IB achieves comparable patient-reported, clinical, and functional outcomes with ACL-R at 2 years postoperatively and, after careful patient selection, should be considered as a valuable early treatment alternative for proximal ACL tears.

REGISTRATION

NCT04429165 (ClinicalTrials.gov identifier).

Stabilization and Gap Formation of Adjustable Versus Fixed Primary ACL Repair With Internal Brace: An in Vitro Full-Construct Biomechanical Cadaveric Study

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.

Ligament augmentation repair is broadly applied across different orthopaedic subspecialities: an ISAKOS international survey of orthopaedic surgeons

OBJECTIVES

To evaluate how ligament augmentation repair (LAR) techniques are currently used in different anatomic regions in orthopaedic sports medicine, and to identify the most common indications and limitations of LAR.

METHODS

We sent survey invitations to 4,000 members of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine society. The survey consisted of 37 questions total, with members only receiving some branching questions specific to their area of specialisation. Data were analysed using descriptive statistics, and the significance between groups was evaluated using chi-square tests of independence.

RESULTS

Of 515 surveys received, 502 were complete and included for the analysis (97% completion rate). 27% of respondents report from Europe, 26% South America, 23% Asia, 15% North America, 5.2% Oceania, and 3.4% Africa. 75% of all survey respondents report using LAR, most frequently using it for the anterior talofibular ligament ( 69%), acromioclavicular joint ( 58%), and the anterior cruciate ligament (51%). Surgeons in Asia report using LAR the most (80%), and surgeons in Africa the least (59%). LAR is most commonly indicated for additional stability (72%), poor tissue quality (54%), and more rapid return-to-play (47%). LAR users state their greatest limitation is cost (62%), while non-LAR users state their greatest reason not to use LAR is that patients do well without it (46%). We also find that the frequency of LAR use among surgeons may differ based on practice characteristics and training. For example, surgeons who treat athletes at the professional or Olympic level are significantly more likely to have a high annual use of LAR (20+ cases) compared to surgeons that treat only recreational athletes (45% and 25%, respectively, p ​= ​0.005).

CONCLUSION

LAR is broadly applied in orthopaedics but its rate of use is not homogeneous. Outcomes and perceived benefits vary depending on factors such as surgeon specialty and treatment population.

LEVEL OF EVIDENCE

Level V.

Arthroscopic Anterior Cruciate Ligament Primary Repair With Synthetic Augmentation and Fixation With the Knotless Suture Anchor

An anterior cruciate ligament (ACL) tear is one of the most common ligament injuries in athletes. The arthroscopic ACL reconstruction procedure is the gold standard for treatment. However, the improvement in injury classification and suture materials has subsequently made arthroscopic ACL primary repair an alternative surgical treatment option. This Technical Note describes an arthroscopic ACL primary repair with synthetic augmentation made of several high-strength sutures and fixation with the knotless suture anchor. The reinforced synthetic material acts as a structural tie to support the ACL while it heals.

Augmentation with Fibertape Leads to Biomechanically Superior but Similar Clinical Outcomes in ACL Surgeries: Systematic Review and Meta-analysis

Purpose

The current generation has witnessed significant progress in the field of knee arthroscopy. Suture tapes have gained immense popularity due to perceived improved biomechanical support to the graft while it heals. The purpose of the present systematic review is to analyze the biomechanical construct of suture tapes in ACL repairs and reconstructions along with clinical outcomes.

Methods

Cochrane Library, PubMed, and Embase were searched until December 2021. All Biomechanical Studies on animal or cadaver knees that compared construct characteristics of suture tape in ACL repair or reconstruction and clinical studies in English focusing on outcomes following suture tape augmentation in ACL repair or reconstruction were included. The quality of clinical studies using the Modified Coleman Methodology Score (MCMS).

Results

A total of 16 studies biomechanical and 23 clinical studies were included in qualitative synthesis, leaving nine biomechanical studies for final quantitative analyses. Suture tape revealed biomechanical superiority in terms of ultimate strength, stiffness, cyclic displacement, and elongation of graft, while comparing ACLR with internal brace to standard ACLR. No significant difference in retear rates was seen in clinical studies. Clinical score(IKDC score) was found similar in both augmented and non-augmented construct. Similar results were obtained in biomechanical studies.

Conclusion

The use of suture tape as a ligament augmentation in both ACL reconstruction and ACL repair offers more strength, less elongation or displacement, and is biomechanically stable and sound. There is a lack of data to comprehensively comment upon the clinical superiority of the use of internal augmentation. However, a meta-analysis of the retear rates and clinical outcome score revealed similar outcomes between suture tape augmented and nonaugmented groups.

Posterior cruciate ligament repair seems safe with low failure rates but more high level evidence is needed: a systematic review

PURPOSE

To discuss recent literature on posterior cruciate ligament (PCL) repair and report on the clinical and radiological outcomes.

METHODS

A systematic review was conducted according to the PRISMA guidelines. In August 2022, three databases (PubMed, Scopus, and Cochrane Library) were searched for studies on PCL repair by two independent reviewers. Articles published between January 2000 and August 2022 focussing on the clinical and/or radiological outcomes, following PCL repair, were included. Patient demographic data, clinical evaluations, patient‑reported outcome measures, post-operative complications and radiological outcomes were extracted.

RESULTS

Nine studies met the inclusion criteria, covering 226 patients with a mean age ranging from 22.4 to 38.8 years and mean follow-up periods ranging from 14 to 78.6 months. Seven studies (77.8%) were level IV and two studies (22.2%) were level III. Arthroscopic PCL repair was performed in four studies (44.4%) while the remaining five studies (55.6%) described open PCL repair. In four studies (44.4%) additional suture augmentation was applied. Arthrofibrosis affected a combined total of 24 patients (11.7%; range 0-21.0%) making it the most common complication and the overall failure rate was 5.6%, ranging from 0 to 15.8%. Two studies (22.2%) performed post-operative MRI and confirmed PCL healing.

CONCLUSION

This systematic review indicates that PCL repair can be a safe procedure with an overall failure rate of 5.6%, ranging from 0% to 15.8%. However, more high quality research is necessary before widespread clinical implementation is warranted.

LEVEL OF EVIDENCE

IV.

Clinical Research Progress of Internal Brace Ligament Augmentation Technique in Knee Ligament Injury Repair and Reconstruction: A Narrative Review

Knee ligament injuries are most common in sports injuries. In general, ligament repair or reconstruction is necessary to restore the stability of the knee joint and prevent secondary injuries. Despite advances in ligament repair and reconstruction techniques, a number of patients still experience re-rupture of the graft and suboptimal recovery of motor function. Since Dr. Mackay's introduction of the internal brace technique, there has been continuous research in recent years using the internal brace ligament augmentation technique for knee ligament repair or reconstruction, particularly in the repair or reconstruction of the anterior cruciate ligament. This technique focuses on increasing the strength of autologous or allograft tendon grafts through the use of braided ultra-high-molecular-weight polyethylene suture tapes to facilitate postoperative rehabilitation and avoid re-rupture or failure. The purpose of this review is to present detailed research progress in the internal brace ligament enhancement technique of knee ligament injury repair as well as the reconstruction from biomechanical and histological research and clinical studies and to comprehensively assess the value of the application of this technique.

Platelet-Rich Fibrin-Augmented Gap-Bridging Strategy in Rabbit Anterior Cruciate Ligament Repair

BACKGROUND

We assessed the efficacy of a novel platelet-rich fibrin (PRF)-augmented repair strategy for promoting biological healing of an anterior cruciate ligament (ACL) midsubstance tear in a rabbit model. The biological gap-bridging effect of a PRF scaffold alone or in combination with rabbit ligamentocytes on primary ACL healing was evaluated both in vitro and in vivo.

HYPOTHESIS

A PRF matrix can be implanted as a provisional fibrin-platelet bridging scaffold at an ACL defect to facilitate functional healing.

STUDY DESIGN

Controlled laboratory study.

METHODS

The biological effects of PRF on primary rabbit ligamentocyte proliferation, tenogenic differentiation, migration, and tendon-specific matrix production were investigated for treatment of cells with PRF-conditioned medium (PRFM). Three-dimensional (3D) lyophilized PRF (LPRF)-cell composite was fabricated by culturing ligamentocytes on an LPRF patch for 14 days. Cell-scaffold interactions were investigated under a scanning electron microscope and through histological analysis. An ACL midsubstance tear model was established in 3 rabbit groups: a ruptured ACL was treated with isolated suture repair in group A, whereas the primary repair was augmented with LPRF and LPRF-cell composite to bridge the gap between ruptured ends of ligaments in groups B and C, respectively. Outcomes-gross appearance, magnetic resonance imaging, and histological analysis-were evaluated in postoperative weeks 8 and 12.

RESULTS

PRFM promoted cultured ligamentocyte proliferation, migration, and expression of tenogenic genes (type I and III collagen and tenascin). PRF was noted to upregulate cell tenogenic differentiation in terms of matrix production. In the 3D culture, viable cells formed layers at high density on the LPRF scaffold surface, with notable cell ingrowth and abundant collagenous matrix depositions. Moreover, ACL repair tissue and less articular cartilage damage were observed in knee joints in groups B and C, implying the existence of a chondroprotective phenomenon associated with PRF-augmented treatment.

CONCLUSION

Our PRF-augmented strategy can facilitate the formation of stable repair tissue and thus provide gap-bridging in ACL repair.

CLINICAL RELEVANCE

From the translational viewpoint, effective primary repair of the ACL may enable considerable advancement in therapeutic strategy for ACL injuries, particularly allowing for proprioception retention and thus improved physiological joint kinematics.

Suture Augmentation in Orthopaedic Surgery Offers Improved Time-Zero Biomechanics and Promising Short-Term Clinical Outcomes

Ligament and tendon ruptures have historically been addressed with varying techniques involving either repair or reconstruction. More recently, the potential biomechanical benefits of suture augmentation (SA), also known as internal brace, have attracted substantial attention and helped renew interest in ligament repair surgery. We evaluated the biomechanical and clinical outcomes of SA-based techniques in the following sports medicine procedures: medial ulnar collateral ligament repair of the elbow, thumb collateral ligament repair, anterior cruciate ligament repair, Achilles' tendon repair, and deltoid ligament repair. Published data on the use of SA to augment repairs of the ulnar collateral ligament, thumb collateral ligament, anterior cruciate ligament, Achilles' tendon, and deltoid ligament repair demonstrates improved time-zero biomechanical and promising short to mid-term clinical outcomes. However, surgeons must be wary of potential complications, including joint over-constraint, nerve paresthesia, and infection.

Comparable rates of secondary surgery between anterior cruciate ligament repair with suture tape augmentation and anterior cruciate ligament reconstruction

Purpose

The aim of this study was to determine the frequency of secondary surgery following anterior cruciate ligament (ACL) repair with suture tape augmentation in comparison to conventional hamstring ACL reconstruction. We hypothesised that there would be no differences between the groups.

Methods

This was a retrospective comparison study of patients undergoing ACL surgery between September 2011 and April 2018. Two hundred and 73 patients underwent ACL reconstruction using hamstring autograft. During the same timeframe, 137 patients with an acute proximal ACL rupture underwent ACL repair with suture tape augmentation. One patient was lost to follow-up in the ACL reconstruction group leaving 272 patients (99.6%) for the final analysis. In the ACL repair group, three patients were lost to follow-up leaving 134 patents (97.8%) for the final analysis. Secondary surgery was identified by contacting the patients by email/telephone and reviewing patient notes at the time of this analysis.

Results

Re-rupture occurred in 32 patients (11.8%) in the ACL reconstruction group compared to 22 patients (16.4%) in the ACL repair group (p = 0.194). Contralateral ACL rupture occurred in four patients (1.5%) in the ACL reconstruction group compared to three patients (2.2%) in the ACL repair group (p = 0.224). In the ACL reconstruction group, nine patients (3.3%) required secondary meniscal surgery whilst five patients (3.7%) required meniscal surgery in the ACL repair group (p = 0.830). Seven other operations were performed in the ACL reconstruction group (2.6%) compared to three other operations in the ACL repair group (2.2%) (p = 0.374). The overall number of patients undergoing secondary surgery in the ACL reconstruction group was 52 (19.1%) in comparison to 30 (22.4%) in the ACL repair group (p = 0.114).

Conclusion

ACL repair with suture tape augmentation for acute proximal ruptures demonstrated comparable rates of secondary surgery with hamstring ACL reconstruction.

Promising functional outcomes following anterior cruciate ligament repair with suture augmentation

PURPOSE

There has been a renewed interest in the repair of the torn anterior cruciate ligament (ACL). Purpose of this study was to evaluate the functional outcome of arthroscopic ACL repair with additional suture augmentation (SA), hypothesizing that isolated ACL ruptures would yield superior patient-reported outcome measures (PROMs) compared to those with concomitant meniscal and/or ligamentous injuries.

METHODS

This is a retrospective analysis of 93 consecutive patients (67 female, median age 42 years) who underwent arthroscopic ACL repair with SA between January 2017 and March 2019 for an acute traumatic ACL tear confirmed by magnetic resonance imaging (MRI). Patients with pre- or intraoperative mid-substance or distal ACL tears and/or poor tissue quality of the ACL remnant were not considered for ACL repair but were scheduled for an ACL reconstruction with a tendon autograft. In patients who underwent ACL repair with SA, the SA construct was proximally stabilized with a flip-button and distally with a suture anchor. Surgery was preferably performed on the day of injury and all surgeries were performed by the same surgeon. Postoperative rehabilitation included partial weight-bearing (20 kg) for 6 weeks and immobilization in a brace limited at 90-degrees of knee flexion for 4 weeks. Patient-reported outcome measures (PROMs) were determined using International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Lysholm Score (LS), Tegner Activity Score (TS) and Forgotten Joint Score (FJS). Knee-laxity was assessed using the KT-1000 arthrometer (Med Metrics Corp. Inc., San Diego, USA).

RESULTS

Nine patients underwent revision surgery for a traumatic re-tear (four patients) and chronic instability (five patients) and were excluded from further functional analysis. Functional results of 77 patients (54 female) with a median age of 44 years (IQR 33-51) on the day of surgery were available for follow-up after a median time of 35 months (IQR 33-44). Concomitant injuries were observed in 66 Patients (86%), meniscal injuries in 43 patients (55%) and ligamentous injuries in 50 patients (65%). Median interval from injury to surgery was 1 day (IQR 0-1) with 81% (62/77) of patients being treated within 24 h of injury. The median IKDC was 92 (IQR 86-99), the median LS was 95 (IQR 86-100), the median pre-traumatic TS was 7 (IQR 6-7), the median post-traumatic TS was 6 (IQR 5-7) with a non-significant median difference (TS_Diff) of 0 (IQR 0-1). The median FJS was 95 (IQR 78-98). KT-1000 measurements were available in 34 of 77 patients with a median postoperative laxity compared to the uninjured side of 1 mm (IQR 0-2). Interval from injury to surgery, patients' age, body mass index (BMI), knee laxity and concomitant ligamentous or meniscal injuries had no statistically significant impact on postoperative PROMs (n.s.).

CONCLUSION

Following arthroscopic ACL repair with SA good-to-excellent functional results were observed. However, a failure rate of 10% cannot be neglected and warrants further attention. Concomitant injuries to the meniscus and/or collateral ligaments do not seem to be associated with inferior PROMs.

LEVEL OF EVIDENCE

Level IV.

Bridge-Enhanced Anterior Cruciate Ligament Repair for Mid-Substance Tear With Concomitant Lateral Meniscus Radial Repair

In recent years, repair of the injured anterior cruciate ligament (ACL) has been subject to a renewed interest as novel arthroscopic techniques have been developed. Specifically, the bridge-enhanced ACL repair is a technique composed of a resorbable protein-based implant combined with autologous blood that is used to bridge the gap between 2 torn edges of a mid-substance ACL tear. This implant is believed to help facilitate healing of a primary suture repair and suture cinch and has since demonstrated noninferiority to ACL reconstruction with autograft at 2-year follow-up. The purpose of this Technical Note is to describe a step-by-step surgical technique of a mid-substance ACL repair using the bridge-enhanced ACL repair system in a case with a concomitant lateral meniscus radial repair.

Primary repair with suture augmentation for proximal anterior cruciate ligament tears: A systematic review with meta-analysis

PURPOSE

To assess the outcomes of arthroscopic primary repair of proximal anterior cruciate ligament (ACL) tears with suture augmentation in the literature.

METHODS

A systematic search was performed using PubMed, EMBASE, and Cochrane for studies reporting on outcomes of primary repair of proximal ACL tears with suture augmentation between 2015 and 2021. Primary outcomes included failure and reoperation rates, whereas secondary outcomes consisted of functional outcomes. Proportion meta-analysis was performed to assess the overall incidence of failure rates. Outcomes of adults and adolescent were reported separately.

RESULTS

Thirteen studies with 418 patients were included in this study (mean age 32 years, mean follow-up 2.0 years, 49% male). There were no randomized studies and overall grade of recommendation was weak. Overall failure rate for primary repair with suture augmentation was 8% (95% CI 3.9-14.4), but this was higher for younger patients (17%; 95% CI 2.5-63.9) than for older patients (6%; 95% CI 3.8-8.9). The risk for additional reoperations, complications, or hardware removal was low (all <2%), while functional outcomes were good to excellent (all >80% of maximum score).

CONCLUSION

Current literature shows that primary repair with suture augmentation is a reliable treatment option for proximal ACL tears with a failure rate of 8% and good functional outcome scores at short-term follow-up. Although functional outcomes were good irrespective of age, failure rates were higher in young patients (17% vs 6%, respectively). There is a need for high-quality comparative studies with large group of patients to compare these outcomes with ACL reconstruction.

Anterior cruciate ligament repair with internal brace augmentation: A systematic review

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.

Editorial Commentary: The Anterior Cruciate Ligament May Be Safer Wearing a Suture Tape Augmentation Seat Belt: Click It or Ticket

Bone-patellar tendon-bone autograft for anterior cruciate ligament (ACL) reconstruction has the most data to support its use. However, there may still be room for improvement, and younger age, insufficient rehabilitation, altered neuromuscular patterns, and precocious return to play can increase risk of graft failure. High strength suture augmentation of soft-tissue repair or reconstruction has gained traction in a variety of applications for the knee, including medial collateral and posteromedial corner, lateral collateral ligament, posterior cruciate ligament, and ACL. For ACL reconstruction, the technique consists of using either suture or suture tape fixed at the femoral and tibial ACL footprints to allow for independent tensioning to back up the separately tensioned ACL reconstruction. The static augment serves as a load-sharing device, allowing the graft to see more strain during earlier levels of graft strain, until graft elongation occurs to a critical level whereby the augment will experience more strain than the graft. Hence, the "seat belt" analogy. This is distinct from static augmentation, where the high strength suture is fixed to the graft. Static augmentation (without tensioning separately from the graft) results in a load-sharing device and increased stiffness, but potential stress shielding compared with the "seat belt." If suture tape augmentation improves patient outcome, it is a worthwhile to "click it."

Accuracy of magnetic resonance imaging in predicting anterior cruciate ligament tear location and tear degree

Purpose

The purpose of this study is to evaluate the reliability of magnetic resonance imaging (MRI) in predicting the location of ACL tears in preoperative planning for anterior cruciate ligament (ACL) repair.

Methods

Thirty-four patients who underwent ACL repair were retrospectively analyzed to compare intraoperative arthroscopic findings with preoperative MRIs.

Results

For identifying type I tears, the sensitivity of MRI was 9.0% and the accuracy of MRI was 8.8%. There was moderate interrater agreement between MRI findings for tear location and tear degree.

Conclusion

MRI alone may not necessarily be accurate in identifying which ACL tears are amenable to repair.

Study design

Retrospective case series; Level of Evidence: IV.

Editorial Commentary: Repair the Anterior Cruciate Ligament When You Can: Add Suture Tape Augmentation and Dress for Success

Preserving the native anterior cruciate ligament (ACL) through primary repair has seen a resurgence over the past few years-rightfully so-given the inherent advantages of repairing the ACL over reconstruction. The issue is how best to repair the ACL and protect it to optimize healing. Suture tape augmentation techniques have shown promising low failure rates, and recent biomechanical studies have demonstrated benefits of the suture tape and optimal fixation methods for ACL repair. So, I believe it is time for orthopaedic surgeons to strongly consider routine suture tape augmentation use for improved outcomes with primary ACL repair.