The Crossing Internal Suture Augmentation Technique to Protect the All-Inside Anterior Cruciate Ligament Reconstruction Graft

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.

Analysis of Graft Types Augmented With an Internal Brace for ACL Reconstruction: A Systematic Review

BACKGROUND

New techniques are being developed to decrease the failure rate of anterior cruciate ligament (ACL) grafts and prevent revision surgery. One such technique involves high-strength suture tape (ST), also referred to as internal bracing. Recent literature has highlighted the use of ST for ACL reconstruction, but no study has compared ST augmentation between graft types.

PURPOSE

To compare the use of ST augmentation for ACL reconstruction based on the type of graft used (ie, bone-patellar tendon-bone [BPTB], quadriceps, hamstring).

STUDY DESIGN

Systematic review; Level of evidence, 5.

METHODS

An online search of multiple databases was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and was completed April 2022 to identify studies related to ST augmentation of ACL grafts.

RESULTS

Of 926 studies identified, 10 met inclusion criteria. Five studies (50%) used hamstring tendon (HT), 3 (30%) used quadriceps tendon (QT), 1 (10%) used BPTB, and 1 (10%) used both HT and QT grafts. HT autografts augmented with ST had decreased dynamic and peak elongation (15%-56%), increased load to failure, and increased initial and final dynamic stiffness compared with controls. There was no significant difference in postoperative physical examination findings (range of motion, Lachman, pivot shift), except that ST-augmented grafts had significantly less laxity after surgery compared with HT alone (0.8 vs 1.9 mm; P < .05). QT allografts with ST augmentation showed increased graft strength. Human QT autograft studies showed higher Knee injury and Osteoarthritis Outcome Score scores compared with controls. BPTB allografts with ST augmentation had decreased cyclic displacement by 31% (P = .015) and increased load (758 ± 128 N; P < .001) and stiffness (156 ± 23 N/mm; P = .003) compared with nonaugmented groups. The complication rate was low or showed no increase in the ST augmentation groups compared with control groups.

CONCLUSION

HT, QT, and BPTB grafts augmented with ST demonstrate an effective method for ACL reconstruction. All graft types with ST augmentation showed no evidence of clinical disadvantage, with some studies indicating significant biomechanical or clinical advantages compared with conventional ACL reconstruction.

Ligamentoplasty in scapholunate instability: short-term results of the "all dorsal scapholunate repair" technique

Injury to the scapholunate complex is the cause of scapholunate instability which can lead to radiocarpal and medio-carpal osteoarthritis. Several ligamentoplasty techniques have been reported for the treatment of chronic scapholunate instability before the osteoarthritis stage. The objective of this study was to assess the short-term results of an "all dorsal scapholunate repair" ligamentoplasty. We report the clinical, radiological and functional results of a retrospective study including 21 patients, operated between June 2019 and December 2020 for a stage 3 or 4 scapholunate instability according to the Garcia Elias classification. With a follow-up of 14.2 months, the pain was 0.1/10 according to the VAS at rest and 4/10 during exercise. Wrist strength was measured at 65% of the opposite side. The flexion-extension range of motion was 105°. Radiologically, there was a reduction of the diastasis and scapholunate angle. Osteolysis areas around the anchors were described in 47% of patients. The mean QuickDASH was 29.2/100, PRWE 24/100 and Mayo wrist score 67.8/100. Eighty-one percent of patients were satisfied. Seventeen patients had returned to work 5.2 months postoperatively. In the case of work-related injury, the functional scores were poorer, with a delayed return to work. This technique provides encouraging results in the short term. Most patients were improved compared to preoperative state. The work-related injury appears to be a poor prognostic factor. A longer-term study is imperative to confirm the maintenance over time of the correction of carpal malalignment and the evolution of the osteolysis areas.Level of evidence: Level IV Retrospective study.

Suture Tape Augmentation of Anterior Cruciate Ligament Reconstruction Increases Biomechanical Stability: A Scoping Review of Biomechanical, Animal, and Clinical Studies

PURPOSE

To (1) assess the available literature reporting on suture tape augmentation in anterior cruciate ligament (ACL) reconstruction and (2) determine what evidence exists to support and oppose the technique in clinical practice.

METHODS

Five databases were systematically searched on November 24, 2021, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Technical, animal, biomechanical, and clinical studies were included. Quality appraisal was conducted according to study type. Data were extracted and reported in tabular and narrative form according to the study design.

RESULTS

In total, 1276 studies were appraised, with 22 studies including 6 biomechanical, 3 animal, 10 technical, and 3 clinical studies. Biomechanical studies reported tape-augmented grafts to withstand 12.2% to 73.0% greater load to failure and 17.0% to 60.2% reduced elongation compared with standard ACL reconstruction. Evidence of load sharing started at 200 N (7-mm graft) and 300 N (9-mm graft), with suture tape augments taking 31% and 20% of the final load (400 N), respectively, in one study. Among animal studies, no significant differences in complications, rates of ligamentization, histologic findings, or evidence of stress shielding were reported. Technical studies differed primarily in the method of fixation of the proximal end of the tape. Clinically, patient-reported outcome measures were mixed among significant and nonsignificant improvements in International Knee Documentation Committee scores and return to sport among tape-augmented groups, with no difference in complications.

CONCLUSIONS

Biomechanically, suture tape augmentation of ACL reconstruction increased the strength of the graft complex and reduced elongation, with early evidence of the "safety belt" effect with load-sharing properties at greater loads established. In animal studies, graft maturation and 4-zone bone healing, and equivalent rates of intra-articular complications were detected in ACL reconstruction with suture tape augmentation. In clinical studies, patient-reported outcomes were mixed between improved and equivalent outcomes with and without suture tape augmentation, whereas graft failure was not adequately powered to be assessed.

CLINICAL RELEVANCE

Suture tape augmentation of ACL reconstruction offers a low-cost method of improving initial biomechanical stability of the ACL graft. Animal and clinical data suggest the complication profile associated with synthetic grafts may not be apparent in tape augmentation. Independent suture tape augmentation may be considered with aims to increase the initial stability of the native ACL graft.

Outcomes after Multiligament Knee Injury Reconstruction using Novel Graft Constructs and Techniques

Clinical outcomes after reconstruction for multiligamentous knee injury (MLKI) can be consistently favorable. However, recent implants and technique advances may allow for improvement in outcomes. Our institution has developed novel graft constructs and techniques for reconstructions with preclinical data supporting clinical use. Our study purpose was to assess clinical outcomes after reconstruction for MKLI using our constructs and techniques. Overall success rate, failure/revision rates, return to work (RTW)/return to sports (RTS) rates, and complications were evaluated testing the hypothesis that novel methods would be associated with clinical benefits with respect to applications and outcomes compared with historical results. We reviewed a single-surgeon, longitudinal database of 42 patients who underwent multiligament reconstruction at our institution using these techniques for at least two-ligament injuries. Visual analogue scale (VAS) pain score and PROMIS (patient-reported outcomes measurement information system) were collected preoperatively and postoperatively at a minimum 1-year follow-up. Among these patients, 33 patients (mean age of 28.9 years, mean body mass index (BMI) of 33.2 kg/m², mean follow-up of 14.2 months) were included for outcomes analyses. With the definition of success as having a VAS score of less than or equal to 2 without revision/salvage surgery due to recurrent/residual instability or arthritis, overall success rate was 88% (29/33). The mean VAS scores improved from 5 ± 2 to 2 ± 2. The mean preoperative PROMIS mental health score was 36.2 ± 7, general health was 33.5 ± 6, pain was 62.7 ± 8, and physical function score was 29.4 ± 3. At the final follow-up, PROMIS MH was 50.2 ± 10, GH was 44.4 ± 9, pain was 54.3 ± 9, and PF was 42.6 ± 8.4. Return to work rate was 94% (31/33), and 52% (17/33) of patients were able to RTS at any level. Our results demonstrated excellent clinical outcomes associated with a primary success rate of 88% and RTW rate of 94%. Intraoperative complications occurred in 9.5% of cases and revision and failure rates were 9% and 3%, respectively. Our initial results suggest that multiligament reconstructions using novel graft constructs and techniques are safe and effective and can be considered an appropriate option for reconstruction of the full clinical spectrum of MLKIs.

Development and Assessment of Novel Multiligament Knee Injury Reconstruction Graft Constructs and Techniques

Multiligament knee injury (MLKI) typically requires surgical reconstruction to achieve the optimal outcomes for patients. Revision and failure rates after surgical reconstruction for MLKI can be as high as 40%, suggesting the need for improvements in graft constructs and implantation techniques. This study assessed novel graft constructs and surgical implantation and fixation techniques for anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), posterior medial corner (PMC), and posterior lateral corner (PLC) reconstruction. Study objectives were (1) to describe each construct and technique in detail, and (2) to optimize MLKI reconstruction surgical techniques using these constructs so as to consistently implant grafts in correct anatomical locations while preserving bone stock and minimizing overlap. Cadaveric knees (n = 3) were instrumented to perform arthroscopic-assisted and open surgical creation of sockets and tunnels for all components of MLKI reconstruction using our novel techniques. Sockets and tunnels with potential for overlap were identified and assessed to measure the minimum distances between them using gross, computed tomographic, and finite element analysis-based measurements. Percentage of bone volume spared for each knee was also calculated. Femoral PLC-lateral collateral ligament and femoral PMC sockets, as well as tibial PCL and tibial PMC posterior oblique ligament sockets, were at high risk for overlap. Femoral ACL and femoral PLC lateral collateral ligament sockets and tibial popliteal tendon and tibial posterior oblique ligament sockets were at moderate risk for overlap. However, with careful planning based on awareness of at-risk MLKI graft combinations in conjunction with protection of the socket/tunnel and trajectory adjustment using fluoroscopic guidance, the novel constructs and techniques allow for consistent surgical reconstruction of all major ligaments in MLKIs such that socket and tunnel overlap can be consistently avoided. As such, the potential advantages of the constructs, including improved graft-to-bone integration, capabilities for sequential tensioning of the graft, and bone sparing effects, can be implemented.

[Research progress of internal tension relieving technique in assisting anterior cruciate ligament reconstruction]

OBJECTIVE

To review the research progress of internal tension relieving technique in assisting anterior cruciate ligament (ACL) reconstruction with tendon grafts.

METHODS

The in vivo and in vitro biomechanical tests, animal experiments, and clinical studies on the use of internal tensioning relieving technique assisted ACL reconstruction in recent years were extensively reviewed, the impact of this technology on the biomechanics, histological changes of grafts, and the clinical effectiveness were analyzed and summarized.

RESULTS

The internal tensioning relieving technique based on non-absorbable high-strength sutures can reduce the risk of relaxation and rupture by enhancing the biomechanical strength of tendon grafts in vitro and in vivo, it shows good biocompatibility and support for the ligamentation of the tendon grafts and the establishment of the direct tendon-bone interface in terms of histology. This technique improves postoperative initial joint stability, range of motion, and functional scores in clinical practic, when combining with the enhanced recovery after surgery can effectively promote patients to return to pre-injury exercise level without serious complications.

CONCLUSION

The preliminary research results have confirmed the efficacy and safety of the internal tension relieving technique on assisting ACL reconstruction, then showes some degree of significance and prospect, but more research is needed to further optimize tension-relieving devices and related surgical techniques, and clarify the specific effects of this technique on graft's structure remodeling, biomechanical function, and long-term clinical results.

Repair and Augmentation with Internal Brace in the Multiligament Injured Knee

The internal brace is a ligament repair bridging concept using braided ultra-high-molecular-weight polyethylene suture tape and knotless bone anchors to reinforce ligament strength to allow early mobilization during early-phase healing. This concept can be used in the management of anterior cruciate ligament, posterior cruciate ligament, anterolateral ligament, medial collateral ligament, posteromedial corner, and posterolateral corner injuries. Ligament reinforcement is a concept in which a graft is reinforced and can be used in all aspects of knee ligament reconstruction. There has been a recent resurgence in ligament repair and recent evidence suggests equivalent outcome results.

Quadriceps Tendon Autograft Anterior Cruciate Ligament Reconstruction With Independent Suture Tape Reinforcement

Anterior cruciate ligament (ACL) injuries are common among adolescent athletes and are rising with increased participation in higher level athletics at earlier ages. In these young patients, often with open physes, soft tissue grafts continue to be the primary graft choice for ACL reconstruction. Reinjury continues to be a concern in this high-risk age group, with failure rates 2 to 3 times higher than in adults. Recently, primary ACL reconstruction with suture tape augmentation/reinforcement has been described in both hamstring autografts and allografts. Purported advantages include protection of the graft during the revascularization and remodeling phase of incorporation. This Technical Note details a surgical technique of independent suture tape reinforcement during primary all soft tissue quadriceps tendon autograft ACL reconstruction using an all-inside technique.