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

Suture Tape Augmentation Improves Posterior Stability After Isolated Posterior Cruciate Ligament Reconstruction Using Hamstring Tendon Autograft With Single-Bundle Transtibial Technique

PURPOSE

To assess whether posterior cruciate ligament reconstruction (PCLR) with suture tape augmentation can yield more stability after isolated PCLR.

METHODS

A prospective database was retrospectively reviewed to identify patients who underwent primary isolated PCLR (control group) or isolated PCLR with suture tape augmentation (study group) from January 2016 to September 2020. We analyzed subjective International Knee Documentation Committee (IKDC), Lysholm, and Tegner knee scores; posterior drawer test findings; posterior stress radiographs; and return-to-sports activity rates. The minimal clinically important difference (MCID) was used to evaluate clinical relevance (subjective IKDC, Lysholm, and Tegner scores).

RESULTS

A total of 59 patients were included in this analysis (28 in control group and 31 in study group). The average length of follow-up was similar between the study and control groups (48.6 months vs 47.9 months, P = .800). Knee function was significantly improved in the study group in terms of subjective IKDC scores (85.1 ± 6.4 in study group vs 79.8 ± 6.4 in control group, P = .002), Lysholm scores (86.3 ± 7.4 vs 80.8 ± 7.4, P = .005), and Tegner scores (7.0 ± 1.4 vs 5.6 ± 1.7, P = .006). However, the differences between the control and study groups were less than the MCID for the subjective IKDC score and Lysholm score. In the control and study groups, 21.4% of patients (6 of 28) and 48.4% of patients (15 of 31), respectively, returned to their preinjury sports activity levels (P = .031). At last follow-up, the mean side-to-side difference in posterior laxity was significantly improved in the study group compared with the control group (1.52 ± 0.70 mm in study group vs 3.17 ± 2.01 mm in control group, P < .01).

CONCLUSIONS

Primary isolated PCLR with suture tape augmentation provides better posterior stability than PCLR without suture tape augmentation at a minimum of 2 years' follow-up. No differences between the groups were observed in the percentage of patients who met or exceeded the MCID for the subjective IKDC and Lysholm scores.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Proximal Tibia Fracture Through Suture Augmentation Sites Following ACL/MCL Repairs: A Case Report

CASE

A 35-year-old man sustained a proximal tibia fracture from a low-energy mechanism 1 year after anterior cruciate and medial collateral ligament repairs with suture augmentation (SA). The fracture propagated through both tibial SA anchor sites. Following intramedullary tibial nailing, he returned to his prior level of function.

CONCLUSION

While complications of SA for ligamentous procedures are rare, these techniques are being implemented more frequently and the full complication profile is yet to be determined. Our report documents a new complication and potential risk factors that surgeons should consider when performing SA for multiligament knee surgery in active individuals.

Analysis of Changing Practice Trends in Anterior Cruciate Ligament Reconstruction: A Multicenter, Single-Institution Database Analysis

PURPOSE

To identify trends in anterior cruciate ligament reconstruction (ACLR), including graft choice, femoral tunnel drilling techniques, and augmentation techniques, and to assess how various surgeon factors impact these trends.

METHODS

A retrospective review of primary ACLRs performed between 2014 and 2022 was completed using a multicenter institutional database. Patient demographic characteristics, graft type, femoral drilling technique, use of extra-articular tenodesis, and use of suture augmentation were recorded from the medical record. Surgeon fellowship training (sports trained vs non-sports trained), experience (high [minimum of 15 years in practice] vs low), and volume (high [minimum of 15 ACLRs/year] vs low) were used to stratify technique utilization. The z test for proportions was used to compare categorical variables. Pearson correlation analyses identified trends and assessed statistical significance, defined as P < .05.

RESULTS

Our cohort consisted of 2,032 ACLRs performed in 2,006 patients. The average patient age was 28.3 ± 11.6 years, with more procedures performed in male patients (67.3%). The average length of surgeon experience was 19.7 ± 11.4 years, with an average annual procedural volume of 4.0 ± 5.4 ACLRs. Most surgeons were sports trained (n = 55, 64.7%), high experience (n = 44, 57.1%), and low volume (n = 80, 94.1%). There was an increasing annual proportion of ACLRs performed by sports-trained surgeons (R = 0.748, P = .020) and low-experience surgeons (R = 0.940, P < .001). Autograft reconstructions were most often performed by sports-trained (71.2%), low-experience (66.1%), and high-volume (76.9%) surgeons. There was an increasing proportion of autograft ACLRs that used quadriceps tendon among sports-trained (R = 0.739, P = .023), high-experience (R = 0.768, P = .016), and low-volume (R = 0.785, P = .012) surgeons. Independent drilling techniques were used in an increasing proportion of ACLRs performed by non-sports-trained (R = 0.860, P = .003) and high-volume (R = 0.864, P = .003) surgeons. Augmentation of ACLR with concomitant suture augmentation (n = 24, 1.2%) or extra-articular tenodesis (n = 6, 0.3%) was rarely performed.

CONCLUSIONS

In our multicenter institution, the quadriceps tendon autograft has been increasingly used in ACLR by sports-trained, low-volume, and high-experience surgeons. Independent drilling techniques have been increasingly used by non-sports-trained and high-volume surgeons.

CLINICAL RELEVANCE

Surgeons must stay current with the literature that affects their procedures to ensure that evidence-based medicine is being practiced.

Ulnar Collateral Ligament Repair With Internal Brace Using Linked Knotless Suture Anchors

This article presents an adaptation of the internal brace ulnar collateral ligament (UCL) repair technique using knotless suture anchors, which shows promise for improved postsurgical functionality and a shortened recovery period in patients with UCL injuries. Traditional methods of UCL reconstruction often require a lengthy 12- to 18-month recovery period, presenting a significant challenge for athletes keen to return to their sport. The modified technique uses smaller sutures and drill holes, thereby eliminating the need for larger anchors and simplifying the surgical process. Furthermore, we provide a comprehensive exploration of the rehabilitation protocol involved after surgery, which includes various phases of physical therapy and use of the "thrower's ten" program to improve shoulder and elbow stability, strength, and mobility. This technique paves the way for a promising alternative to traditional UCL reconstruction or repair methods, with the potential to significantly enhance clinical outcomes, improve recovery times, and positively impact athletes' lives.

Editorial Commentary: Time-Zero Biomechanical Studies Show Suture Augmentation of a Soft-Tissue Graft Improves Its Properties, But They Need to Be Interpreted With Caution

There is emerging evidence in biomechanical studies that suture augmentation of a soft-tissue graft can improve its elongation, stiffness, and load to failure. However, all biomechanical studies have the intrinsic drawback of not considering loosening, accommodation, and mainly, healing. In the past, many very strong and stiff synthetic grafts produced poor results for anterior cruciate ligament reconstruction, and synthetic material inside the joint was abandoned for awhile. Recent studies have shown that it is possible to use synthetic material to augment the graft instead of being the graft itself. But the question we need to ask ourselves is: Does it really work in the clinical scenario? Undoubtedly, there is still a way to go to incorporate suture augmentation into soft-tissue grafts in knee reconstruction, and it is mandatory to start high-level clinical studies to prove its real benefit to ligament reconstruction results.

Acute Percutaneous Repair of Medial Collateral Ligament With Suture Augmentation in the Multiligamentous Injured Knee Results in Good Stability and Low Rates of Postoperative Stiffness

Purpose

To assess the clinical and patient-reported outcome measures (PROMs) of acute superficial medial collateral ligament (sMCL) repair with suture augmentation (SA) in the setting of a multiligamentous injured knees (MLIKs) at 2-year follow-up.

Methods

A retrospective analysis of consecutive patients with MLIK with grade III sMCL injuries who underwent acute (<6 weeks) sMCL repair with SA was conducted. Clinical follow-up was performed at minimum 1-year postoperatively, and PROMs were collected at the latest follow-up (minimum 2 years' postoperatively). Continuous variables were reported in median with interquartile range (IQR).

Results

A total of 20 patients (41.4 [28.5-47.9] years of age) with grade III sMCL injury and additional injury to 1 cruciate ligament (KDI-M; n = 13) or bicruciate (KDIII-M; n = 7) were enrolled with a median follow-up of 4.3 (3.6-5.2) years. In total, 90% (n = 18) of patients with MLIK treated with acute sMCL repair and early range of motion rehabilitation protocol demonstrated negative valgus laxity stress testing in 0 and 30° flexion and low reoperation rates (n = 1, 5%) due to stiffness. In addition, good-to-excellent subjective outcomes were reported at final follow-up: median International Knee Documentation Committee 82.2 (78.7-90.8), Lysholm 95.0 (90.0-100.0), modified Cincinnati Score 89.0 (83.3-96.0), Single Assessment Numeric Evaluation 90.0 (83.8-95.0), Forgotten Joint Score 79.2 (62.5-91.7), Tegner 5.0 (IQR 4.0-6.0), and ACL-Return to Sport after Injury Scale 78.3 (IQR 66.7-90.0).

Conclusions

In this study, 20 heterogenous patients with MLIKs treated with acute percutaneous sMCL repair with SA had excellent stability, low rates of postoperative stiffness, and good-to-excellent PROMs at short-term follow-up.

Level of Evidence

Level IV, therapeutic case series.