Independent Suture Tape Internal Brace Reinforcement of Bone-Patellar Tendon-Bone Allografts: Biomechanical Assessment in a Full-ACL Reconstruction Laboratory Model

Arthroscopic Anterior Talofibular Ligament Repair Combined With All-Inside Suture Tape Augmentation for Treatment of Chronic Lateral Ankle Instability With Generalized Joint Laxity

BACKGROUND

To analyze the feasibility and clinical results of the modified Broström operation (MBO) combined with suture tape augmentation under arthroscopy for chronic lateral ankle instability (CLAI) in patients with generalized joint laxity (GJL).

METHODS

From October 2019 to October 2021, a total of 111 patients (111 ankles) treated with MBO combined with suture tape augmentation under arthroscope were retrospectively divided into a GJL group (29 patients) and a control group (82 patients). Mechanical stability of the affected ankle joint was evaluated radiographically preoperatively, at 6 months postoperatively, and the last follow-up. Complications and surgical failures, as well as visual analog scale (VAS) score, the Foot and Ankle Ability Measure (FAAM), and the Karlsson score were also recorded. All statistical analyses were completed using SPSS 20.0.

RESULTS

The average follow-up time was 21.7 ± 5.2 months for the GJL group, and 20.9 ± 5.3 months for the control group. Pain and symptoms in both groups were effectively relieved by the procedure reflected by decreased VAS scores, improved FAAM and Karlsson scores at 6 months postoperatively, and the final follow-up (P < .05). Preoperative talar tilt angle and anterior talar translation were significantly greater in the GJL group than those in the control group (P < .05). Postoperatively, both talar tilt angle and anterior talar translation were reduced in both groups at 6 months postoperatively and the last follow-up (P < .05), and we found no significant difference between the two groups (P > .05). Furthermore, we found no significant difference in VAS, FAAM, and Karlsson scores between the 2 groups 6 months postoperatively and at the last follow-up.

CONCLUSION

Arthroscopic MBO combined with suture tape augmentation is a reliable procedure for treating CLAI with GJL. At short-term follow-up, we found that the GJL group achieved an equivalent level of stability compared with the control group.

Anterior Cruciate Ligament (ACL) Reconstruction Augmentation With Bone Marrow Aspirate, Demineralized Bone Matrix, and Suture Tape Demonstrates No Difference In Outcomes, But Faster Functional Recovery, Versus Non-augmented ACL Reconstruction

PURPOSE

To compare outcomes after anterior cruciate ligament reconstruction (ACLR) with bone marrow aspirate concentrate (BMAC), demineralized bone matrix (DBM), and suture tape augmentation (STA) vs. ACLR without biologic augmentation or STA.

METHODS

A prospective randomized controlled trial at a single institution was performed to compare ACLR with BMAC, DBM, and STA (Group A) vs. ACLR without biologic or STA (Group NA). One hundred patients were required. Skeletally mature patients <25 years old received quadriceps tendon autografts, while patients ≥25 years old received allograft ACLR with an all-inside technique. Concomitant meniscal pathologies were included. Primary outcomes compared were range-of-motion (ROM), limb symmetry, and patient-reported outcomes (PROs). Secondary outcomes included radiographic outcomes and surgical complications. Univariate and mixed-model regression analysis were used to compare outcomes.

RESULTS

Fifty-nine patients were included (Group A: 29 patients, 11 females, 38%; Group NA: 30 patients, 15 females, 50%). Early range-of-motion at 6 weeks (125° vs 109° flexion, p<0.0001) and limb symmetry testing at 12 weeks (80.6 % vs. 36.7% [Delta 43.9%], p<0.001) were significantly improved in Group A. At two years, International Knee Documentation (IKDC) scores were similar (91.1 ± 12.7 vs. 85.3 ± 10.8, p=0.109). Knee Injury and Osteoarthritis and Outcome Score (KOOS) Quality of Life (QOL) scores were significantly enhanced in Group A (85.2 ± 20.9 vs. 72.1 ± 20.4, p=0.042). Twenty-two patients (12 Group A, 10 Group NA) underwent CT scans at 6-months to compare bone tunnel healing. Overall, the mean increase in bone tunnel diameter was significantly smaller in Group A vs. NA. No difference in graft re-ruptures or re-operations was observed. Seven of 59 patients (11.9%) underwent re-operation for stiffness (A: 3 (10%) vs. NA: 4 (13%), p=1.0).

CONCLUSION

There were no differences in IKDC scores between groups at 2-year follow-up. Functional outcomes including early range-of-motion and limb symmetry were significantly improved in patients who received ACLR with BMAC, DBM, and STA. ACLRACLR.ACLR.

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.

Clinical efficacy and kinematic analysis of Chinese knotting technique-assisted posterior cruciate ligament reconstruction: A retrospective analysis

To investigate the clinical efficacy and knee joint kinematic changes of posterior cruciate ligament (PCL) reconstruction assisted by Chinese knotting technique (CKT). A retrospective analysis was conducted on 88 cases of PCL reconstructive surgery admitted between September 2016 and September 2020. All patients were operated on by the same senior doctor and his team. The patients were divided into 2 groups according to whether the CKT was applied, with 44 cases in each group. Both groups received active rehabilitation treatment after surgery. All patients were followed up for more than 2 years. International knee documentation committee, hospital for special surgery (HSS), and Lysholm scores were used to evaluate the clinical efficacy of the 2 methods at 3, 12, and 24 months after surgery. The motion cycle and kinematic indices of the knee joint were measured by the Opti_Knee three-dimensional motion measurement system before surgery and at 3, 12, and 24 months after surgery. A secondary arthroscopic examination was performed at 12 months after surgery, MAS score was used to evaluate the secondary endoscopic examination of PCL. All the patients had wound healing in stage I without infection. International Knee in both sets Documentation Committee scores, HSS scores and Lysholm scores were gradually improved at all time points (P < .05); compared with the traditional group, the HSS score was higher in the reduction group 12 months after surgery (P < .05), but there was no significant difference at 24 months after surgery. 12 months and 24 months after 3 dimensional motion measurement system using Opti_Knee showed a reduction group before and after displacement and displacement of upper and lower range than the traditional group (P < 0. 05). One year after surgery, the good and good rate of MAS score reduction group was higher than traditional group. CKT assisted PCL reconstruction can improve the subjective function score of the affected knee joint and the results of secondary microscopy. Satisfactory knee kinematic function can be obtained in the early stage, and the anteroposteric relaxation of the knee joint can be reduced.

Quadriceps Tendon Autograft ACL Reconstruction With Suture Tape Augmentation: Safe Results Based on Minimum 2-Year Follow-up MRI

Background

The potential intra-articular effects of ≥1 year after anterior cruciate ligament reconstruction (ACLR) with independent suture tape augmentation (STA) are not fully understood.

Purpose

To investigate whether incorporating suture tape in an all-soft tissue quadriceps tendon autograft (QTA) ACLR leads to satisfactory patient outcomes while having no intra-articular side effects as determined by magnetic resonance imaging (MRI).

Study Design

Case series; Level of evidence, 4.

Methods

Included were 25 patients with a mean age of 19.9 years (95% CI, 17.3-22.5 years) who underwent QTA ACLR with STA between 2016 and 2019. All patients underwent MRI at ≥1 year postoperatively and had at least a 2-year follow-up (mean, 28 months [95% CI, 26.5-29.5 months]) that included physical examination with anterior laxity testing with KT-1000 arthrometer, radiographs, and patient-reported outcome measures (PROMs). At the final follow-up, the minimal clinically important difference (MCID) and the Patient Acceptable Symptom State (PASS) for applicable PROMs were applied to each patient. Postoperative graft and joint integrity were assessed using the Howell classification and the MRI Osteoarthritis Knee Score (MOAKS) joint effusion/synovitis grade. The Mann-Whitney U test for continuous variables and the chi-square or the Fisher exact test for categorical variables were used for statistical analyses.

Results

The MRI assessment of the grafts demonstrated intact grafts in all patients. Overall, 96% of patients demonstrated grades 0 or 1 MOAKS for joint effusion/synovitis. All patient outcomes significantly improved from preoperatively to the final follow-up (P < .001), except for the Marx score, which decreased significantly (14.2 [95% CI, 12.7-15.8] vs 9.72 [95% CI, 7.3-12.2]; P = .0014). At least 68% of the patients achieved the MCID threshold, and 92% achieved the PASS threshold for all applicable PROMs.

Conclusion

QTA ACLR with STA did not demonstrate adverse intra-articular changes on MRI at ≥1 year postoperatively. In addition, STA did not appear to negatively affect PROMs.

Primary Anterior Cruciate Ligament Reconstruction with Suture Tape Augmentation: A Case Series of 252 Patients

Anterior cruciate ligament reconstruction (ACLR) using suture tape augmentation to internally brace is a relatively new technique. The primary goal of this study was to prospectively collect patient-reported outcomes (PROs) and surgical history from patients who underwent primary ACLR with internal bracing to determine if internal bracing resulted in a low graft failure rate while maintaining acceptable PROs. A total of 252 patients with a mean age of 23.6 years (95% confidence interval [CI]: 22.1-25.1) and a mean follow-up of 37.9 months (95% CI: 35.8-40.0) were included in this study. Patients who underwent primary ACLR with internal brace augmentation between July 12, 2016 and July 31, 2021 were eligible. A total of 222 patients were contacted via telephone and administered the visual analog scale (VAS), the single assessment numeric evaluation (SANE), the Lysholm knee score scale, and, if applicable, the short version ACL return to sport after injury (SV-ACL-RSI) survey. Additionally, patients were asked to give an updated orthopaedic history. Thirty additional patients were included from either our institution's registry or by completing their surveys in-office or by e-mail. The minimal clinically important difference (MCID) and patient-acceptable symptom states (PASS) were calculated based on our patient population and applied to each individual patient. The patients' electronic health record (EHR) was searched for pre- and postoperative clinical data including KT-1000 arthrometer measurements. Two patients (0.8%) had subsequent graft failures and one patient (0.4%) required a revision surgery. MCID was achieved in 242 patients (96.0%) for the Lysholm, 227 patients (90.1%) for the SANE, and 146 patients (57.9%) for the VAS. PASS was achieved in 214 patients (84.9%) for the Lysholm, 198 patients (78.6%) for the SANE, and 199 (80.0%) patients for the VAS, postoperatively. Of note, 65 patients (25.8%) exceeded the PASS threshold for the VAS preoperatively. A total of 127 patients (84.4%) met the cutoff of ≥60/100 for the SV-ACL-RSI survey postoperatively. Postoperative KT-1000 measurements showed near-identical side-to-side differences at both the 13.6-kg pull and manual maximum pull. When stratifying patients based on age at the time of surgery, it was noted that patients younger than 25 years had significantly higher SANE scores (91.6 [95% CI: 90.2-92.9] vs. 82.6 [95% CI: 79.0-86.2]; p < 0.0001) and lower VAS pain scores (0.7 [95% CI: 0.5-0.8] vs. 1.2 [95% CI: 0.8-1.5]; p = 0.004). Primary ACLR with internal bracing led to acceptable patient outcomes and a graft failure rate of less than 1%. LEVEL OF EVIDENCE:: case series, IV.

Primary All-Soft Tissue Quadriceps Tendon Autograft Anterior Cruciate Ligament Reconstruction With Suture Tape Augmentation Resulted in Satisfactory Patient Outcomes and a Low Graft Failure Rate in High School and Collegiate Athletes

PURPOSE

To evaluate ≥2-year patient outcomes after primary all-soft tissue quadriceps tendon autograft (ASTQ) anterior cruciate ligament reconstruction (ACLR) with suture tape augmentation (STA) in skeletally mature high school and collegiate athletes.

METHODS

All high school and collegiate athletes who underwent primary ASTQ ACLR with STA with a minimum of 2-year follow-up were analyzed retrospectively. Patients were administered validated patient-reported outcome measures (PROMs) pre- and postoperatively. The minimal clinically important difference was calculated for each PROM based on this study population and applied to the individual patient. Return to sport, subsequent surgical intervention including contralateral ACLR, and KT-1000 arthrometer measurements for knee laxity were collected. Complications were assessed by physical examination, radiologic studies, or obtained via telephone.

RESULTS

In total, 60 patients were included in the final data analysis, with a mean age of 16.8 years (95% confidence interval 13-23) and mean final follow-up of 37.1 months (95% confidence interval 33.1-41.1). Twelve patients (20%) required subsequent surgery on the ipsilateral knee, which included 7 patients having a subsequent meniscal procedure and 3 patients who underwent arthrolysis. None sustained a graft failure, and 6 patients sustained a contralateral ACL injury necessitating surgery. All PROMs improved at the final follow-up (P < .001). In addition, KT-1000 arthrometer measurements significantly improved postoperatively at 1-year clinical follow-up (P < .001). Most patients obtained the minimal clinically important difference thresholds for each PROM at the final follow-up. There were 48 patients (80%) who participated in pivoting sports. The return-to-sport rate at same level was 54 patients (90%), with 6 patients (10%) not returning to the same level because of graduation.

CONCLUSIONS

ASTQ ACLR with STA in a young athletic patient population may result in a low graft failure rate while maintaining satisfactory patient outcomes at short-term follow-up, including a return to sport at the same level of 90%.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Less Subsequent Revision Anterior Cruciate Ligament (ACL) Reconstruction Following Primary Bone-Patellar Tendon-Bone ACL Reconstruction with Suture Tape Augmentation-A Retrospective Comparative Therapeutic Trial With 5-Year Follow-up

PURPOSE

To investigate patient outcomes, including revision rate, following primary bone patellar-tendon bone autograft (BPTB) anterior cruciate ligament reconstruction (ACLR) with and without suture tape augmentation (STA) in a young and active cohort.

METHODS

All eligible patients who received primary BPTB ACLR with a minimum of 2-year follow-up were included in this retrospective cohort study. All patients receiving STA were augmented with the same device. Patients completed the following patient-reported outcome measures (PROMs): the visual analog scale, the Single Assessment Numeric Evaluation, the Knee Injury and Osteoarthritis Outcome Score subscales, and the Tegner activity scale. Anteroposterior knee laxity was assessed using a KT-1000 arthrometer preoperatively and 1-year postoperatively. Posterior tibial slope, femoral tunnel angle, and tibial tunnel placement were calculated for all patients. Subsequent surgical interventions and return to sport (RTS) were obtained from each patient.

RESULTS

One hundred fourteen patients (52 BPTB ACLR with STA, 62 traditional BPTB ACLR) with a mean patient age <19 years and a mean final follow-up of ≥5 years were included. Compared with the control group, the STA group demonstrated significantly less subsequent revision ACLR (0 vs. 5, P = .036). All PROMs and KT-1000 measurements improved at final follow-up (P < .001) and were comparable between groups. There were no differences seen in either posterior tibial slope or graft tunnel placement between groups. More than 85% of the patients were able to return to the sport that led to their injury at full capacity with no differences seen in RTS rate, time to RTS, or level of competition between groups.

CONCLUSIONS

Compared with traditional BPTB ACLR, additional STA appeared to safely and effectively lead to less subsequent revision ACLR while maintaining acceptable PROMs and objective joint laxity measurements in a young and active patient population.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Suture Augmentation of a Four-Strand Semitendinosus Graft Improves Time-Zero Biomechanical Properties

PURPOSE

To compare the time-zero biomechanical properties of hamstring graft preparations with or without suture augmentation for anterior cruciate ligament reconstruction (ACLR) in a full-construct cadaveric model.

METHODS

Hamstring grafts were harvested from 24 fresh frozen human cadavers and prepared in 1 of 3 ways: quadrupled SemiTendinosus (SemiT), and quadrupled SemiT with suture augmentation (SemiT+2.0-mm tape or SemiT+1.3-mm tape; n = 8 per group). Adjustable loop suspensory implants and cortical buttons were used for fixation on a porcine tibia and acrylic block. Testing included force-controlled cyclic loading at 250 N and 400 N followed by load to failure.

RESULTS

The 2 suture augmentation groups had less total elongation and increased stiffness compared to the nonsuture-augmented group (P = .025). The SemiT+2.0-mm tape group had 36% less total elongation and 34% increased stiffness compared to SemiT+1.3mm tape (P < .001).

CONCLUSIONS

Suture augmentation improves construct biomechanics at time zero following hamstring tendon ACLR. Augmentation with 2.0-mm tape suture improves construct biomechanics compared to 1.3-mm tape suture.

CLINICAL RELEVANCE

Independent suture augmentation of a quadrupled SemiT graft improves ACLR construct biomechanics. Outcomes were improved with augmentation using 2.0-mm tape suture compared to 1.3-mm tape suture.

Outcomes of Anterior Cruciate Ligament Reconstruction With Independently Tensioned Suture Tape Augmentation at 5-Year Follow-up

BACKGROUND

Reconstruction using autograft remains the gold standard surgical treatment for anterior cruciate ligament (ACL) injuries. However, up to 10% to 15% of patients will suffer a graft failure in the future. Cadaveric studies have demonstrated that the addition of suture tape augmentation to ACL autograft constructs can increase graft strength and reduce elongation under cyclical loading.

PURPOSE/HYPOTHESIS

This study aimed to investigate the clinical outcomes and rerupture rates after ACL reconstruction (ACLR) with suture tape augmentation. We hypothesized that augmentation with suture tape would lead to lower rerupture rates.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients undergoing primary ACLR using hamstring or patellar tendon autografts augmented with suture tape between 2015 and 2019 were recruited prospectively. Patients with multiligament injuries or a concomitant lateral extra-articular procedure were excluded. Patients were observed in person for 6 months, and patient-reported outcome measures (PROMs) were collected at 2 and 5 years postoperatively. All patients were contacted, and records were reviewed to determine the incidence of graft failure. PROMs collected were as follows: Knee injury and Osteoarthritis Outcome Score (KOOS), Veterans RAND 12-Item Health Survey (VR-12), Tegner and Marx activity scores, and visual analog scale for pain (VAS).

RESULTS

A total of 97 patients, with a mean age of 34.7 (±13.4) years, were included (76% men; 52 hamstring and 45 patellar tendon grafts). The mean graft diameter was 8 (±1) mm. There was 1 rerupture (1.1%) out of the 90 patients who were contactable at a mean of 5 years postoperatively. Median KOOS scores at 2 years were as follows: Pain, 94; Symptoms, 86; Activities of Daily Living, 99; Sport and Recreation, 82; and Quality of Life, 81. The postoperative scores were significantly higher than the preoperative scores (P < .001). The VR-12 Physical score improved from 43 preoperatively to 55 at 2 years and remained at 56 at 5 years. The VAS pain, Tegner, and Marx scores were 0, 6, and 9, respectively, at 2 years postoperatively. There was no difference in PROMs between graft types.

CONCLUSION

This study demonstrates encouraging results of suture tape augmentation of autograft ACLR for both hamstring and patellar tendon grafts. The failure rate of 1.1% at a mean follow-up of 5 years is lower than published rates for reconstruction, and PROMs results are satisfactory. The technique is safe to use and may permit a return to the preinjury sporting level with a lower chance of reinjury.

Evaluation of biomechanical properties and biocompatibility: are partially absorbable cords eligible for anterior cruciate ligament reconstruction?

Introduction: Independent augmentation technology based on reinforcing devices has been reported to signifi-cantly reduce the elongation behavior of graft and improve knee stability after anterior cruciate ligament reconstruction (ACLR). Using biodegradable devices could reduce the risk of severe inflammatory reactions due to particle accumulation from foreign bodies. Given the limitations of the mechanical properties of biodegradable materials, partially biodegradable composite devices may offer a compromise strategy. Methods: Three types of partially absorbable core-sheath sutures, including low-absorbable cord (LA-C), medium-absorbable cord (MA-C) and high-absorbable cord (HA-C), were braided using unabsorbable ultra-high molecular weight polyethylene (UHMWPE) yarn and absorbable polydioxanone (PDO) monofil-ament bundle based on the desired configuration. The feasibility of these partially absorbable cords were verified by biomechanical testing, material degradation testing, and cell experiments, all performed in vitro. Results: Reinforcement of an 8 mm graft with the cords decreased dynamic elongation by 24%-76%, was positively related to dynamic stiffness, and increased the failure load by 44%-105%, during which LA-C showed maximum enhancement. Human ligament-derived fibroblasts showed good proliferation and vitality on each cord over 2 weeks and aligned themselves in the direction of the fibers, especially the UHMWPE portion. Discussion: This study supports the potential of partially degradable UHMWPE/PDO cords, particularly LA-C, for graft protection. Nervertheless, a higher proportion of biodegradable material results in lower stiffness, which may impair the protective and lead to mechanical instability during degradation.

Reduced Incidence of Revision Anterior Cruciate Ligament Reconstruction With Internal Brace Augmentation

Background

Revision rates and outcome measures after anterior cruciate ligament reconstruction (ACLR) with suture tape as an internal brace is not well-documented because of the emerging nature of the technique.

Hypothesis

ACLR with internal bracing (IB) would lead to decreased revision ACLR compared with traditional ACLR while exhibiting comparable patient outcomes.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 200 patients were included in this study. Patients aged between 13 and 39 years at the time of surgery who underwent primary autograft ACLR with IB between 2010 and 2020 and were enrolled in our institution's registry with a minimum of 2-year follow-up were identified and matched 1 to 1 with a non-internal brace (no-IB) group based on concomitant procedures and patient characteristics. Pre- and postoperatively, patients completed the Knee injury and Osteoarthritis Outcome Score, Marx activity rating scale, Veterans RAND 12-Item Health Survey, and visual analog scale for pain. Knee laxity measurements via the KT-1000 arthrometer were included in the pre- and postoperative objective clinical assessments.

Results

A total of 100 IB patients were matched with 100 no-IB patients based primarily on concomitant procedures and secondarily on patient characteristics. The IB group underwent significantly fewer revision ACLRs (1% vs 8%; P = .017). Even though the no-IB group had a significantly longer mean final follow-up time (48.6 months [95% CI, 45.4-51.7] vs 33.4 months [95% CI, 30.3-36.5]; P < .001), the time elapsed from the original ACLR to the revision did not differ significantly between groups, and the mean ages for the IB and no-IB groups were comparable (19 vs 19.9 years). All postoperative patient-reported outcome scores between the 2 groups were comparable and significantly improved postoperatively except for the Marx score, which significantly decreased stepwise for both groups postoperatively. KT-1000 measurements significantly improved in both groups after surgery with the IB and no-IB cohorts yielding comparable results at the manual maximum pull (0.97 vs 0.65 mm).

Conclusion

ACLR with IB resulted in a significantly decreased risk of revision ACLRs while maintaining comparable patient-reported outcomes. Therefore, incorporating an internal brace into ACLR appears to be safe and effective within these study parameters.

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.

Suture-tape augmentation of anterior cruciate ligament reconstruction: a prospective, randomised controlled trial (STACLR)

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction aims to restore anteroposterior and rotatory stability to the knee following ACL injury. This requires the graft to withstand the forces applied during the process of ligamentisation and the rehabilitative period. We hypothesise that the use of suture tape augmentation of single bundle ACL reconstruction (ACLR) will reduce residual knee laxity and improve patient-reported outcomes at 2-year follow-up. We will conduct a 1:1 parallel arm single-centre randomised controlled trial comparing suture tape augmented ACLR to standard ACLR technique.

METHODS

The study design will be a parallel arm 1:1 allocation ratio randomised controlled trial. Sixty-six patients aged 18 and over waitlisted for primary ACLR will be randomised. Patients requiring osteotomy and extra-articular tenodesis and who have had previous contralateral ACL rupture or repair of meniscal or cartilage pathology that modifies the post-operative rehabilitation will be excluded. The primary outcome measure will be the side-to-side difference in anterior tibial translation (measured on the GNRB arthrometer) at 24 months post-surgery. GNRB arthrometer measures will also be taken preoperatively, at 3 months and 12 months post-surgery. Secondary outcomes will include patient-reported outcome measures (PROMs) collected online, including quality of life, activity and readiness to return to sport, complication rates (return to theatre, graft failure and rates of sterile effusion), examination findings and return to sport outcomes. Participants will be seen preoperatively, at 6 weeks, 3 months, 12 months and 24 months post-surgery. Participants and those taking arthrometer measures will be blinded to allocation.

DISCUSSION

This will be the first randomised trial to investigate the effect of suture-tape augmentation of ACLR on either objective or subjective outcome measures. The use of suture-tape augmentation in ACLR has been associated with promising biomechanical and animal-level studies, exhibiting equivalent complication profiles to the standard technique, with initial non-comparative clinical studies establishing possible areas of advantage for the technique. The successful completion of this trial will allow for an improved understanding of the in situ validity of tape augmentation whilst potentially providing a further platform for surgical stabilisation of the ACL graft.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry ACTRN12621001162808. Universal Trial Number (UTN): U1111-1268-1487. Registered prospectively on 27 August 2021.

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.

Biomechanical comparison of two InternalBrace™ reinforced thumb ulnar collateral ligament reconstruction techniques

BACKGROUND

Chronic ulnar collateral ligament ruptures of the thumb metacarpophalangeal joint are often not eligible for direct surgical repair and ligament reconstruction could be considered. Several reconstruction techniques are published, with different types of configurations and fixation methods of the tendon grafts. However, failure of the reconstruction with recurrent instability is still a problem, despite stable graft to bone fixation. Augmentation of the free tendon graft with non-resorbable suture material is gaining popularity, aiming to withstand elongation or rupture of the graft. The purpose of this study was to compare two different augmented ulnar collateral ligament reconstruction methods in a cadaver model.

METHODS

Ten matched pairs of cadaveric upper extremities were used. The thumbs were disarticulated at the trapezometacarpal joint and the ulnar collateral ligament was excised then reconstructed with InternalBrace™ reinforced tendon graft, which was fixed to the bones using either a Tenodesis screw or DX Swivelock® anchor. The thumbs were biomechanically tested with valgus stress, while the force and displacement were simultaneously measured and plotted.

FINDINGS

The mean (SD) load at clinical failure and maximum load were 19.4 (5.3) and 31.4 (9.5) N in the Tenodesis group, and 21.0 (10.0) and 31.4 (13.9) N in the DX SwiveLock® group, respectively. None of these differences were significant. These results are comparable with previous publications.

INTERPRETATION

The Tenodesis screw and the DX SwiveLock® thumb ulnar collateral ligament reconstruction with InternalBrace™ reinforced free tendon graft showed equal strength, both methods are feasible alternatives in the clinical setting.

Comparison of Posterior Cruciate Ligament Reconstruction Using an All-Inside Technique With and Without Independent Suture Tape Reinforcement

Background

Biomechanical studies support the use of suture tape reinforcement for limiting graft elongation and increasing strength in knee ligament reconstructions.

Purpose

To compare posterior cruciate ligament (PCL) laxity, complication and reoperation rates, and patient-reported outcomes (PROs) after all-inside single-bundle PCL reconstruction (PCLR) with versus without independent suture tape reinforcement.

Study Design

Cohort study; Level of evidence, 3.

Methods

A retrospective cohort study of consecutive patients who underwent primary, all-inside allograft single-bundle PCLR with and without independent suture tape reinforcement at a single academic institution from 2012 to 2019. Medical records were reviewed for patient characteristics, additional injuries, and concomitant procedures. PRO scores (including the International Knee Documentation Committee [IKDC], Tegner activity scale, and Lysholm scores), bilateral comparison kneeling radiographs, and physical examination findings were collected at a minimum of 2 years postoperatively.

Results

Included were 50 patients: 19 with suture tape reinforcement (mean age 30.6 ± 2.9 years) and 31 without suture tape reinforcement (control group; mean age 26.2 ± 1.6 years). One PCLR graft in the suture tape group failed. Posterior drawer examination revealed grade 1+ laxity in 4 of 19 (21%) of the suture tape cohort versus 6 of 31 (19%) of the control cohort (P > .999). Bilateral kneeling radiographs showed similar side-to-side differences in laxity between the groups (suture tape vs control: mean, 1.9 ± 0.4 vs 2.6 ± 0.6 mm; P = .361). There were no statistically significant differences between the groups in postoperative IKDC (suture tape vs control: 79.3 vs 79.6; P = .779), Lysholm (87.5 vs 84.3; P = .828), or Tegner activity (5.6 vs 5.7; P = .562) scores.

Conclusion

All-inside single-bundle PCLR with and without independent suture tape reinforcement demonstrated low rates of graft failure, complications, and reoperations, with satisfactory PROs at a minimum 2-year follow-up. Radiographic posterior tibial translation was comparable between the 2 groups.

The Chinese knotting technique assist anatomical anterior cruciate ligament reconstruction for aggressive rehabilitation

Aggressive rehabilitation after anterior cruciate ligament (ACL) reconstruction may result in better clinical outcomes and fewer complications such as knee stiffness and weakness. We explored the effect of the Chinese knotting technique (CKT) for aggressive rehabilitation after ACL reconstruction. Ninety-one anatomical ACL reconstruction cases from 2016 to 2020 were retrospectively reviewed. All patients were operated by the same senior physician and his team. According to the reconstruction with or without CKT, the patients were divided into 2 groups. Both groups received aggressive rehabilitation. The follow-up time of 91 patients was more than 2 years. In total, 43 out of the 91 patients were in the CKT group, and 48 were in the routine group. The knee joint kinematics recorded by Opti_Knee revealed no significant difference among the CKT group, the routine group, and healthy adults at 3, 6, 12, and 24 months after the operation, respectively. The internal and external rotation angle and the anteroposterior displacement at 3 and 6 months after the operation in the CKT group were smaller than in the routine group and were similar to that of the healthy adults. There was no significant difference in flexion and extension angle, varus or valgus angle, proximal-distal displacement, or the internal or external displacement between the 2 groups. In addition, there was no significant difference in 6 degrees of freedom of the knee between the 2 groups at 12 and 24 months after the operation, respectively, which was similar to healthy adults. Compared to the routine group, the International Knee Documentation Committee scores were significantly higher in the CKT group at the 3, 6, and 12 months, respectively, but no difference was observed at 24 months (P = .749). The Lysholm score was significantly higher in the CKT group at the 3 and 6 months postoperatively, while there was no difference at 12 and 24 months, respectively. In short-term observation, the ACL reconstruction with CKT, which can sustain aggressive rehabilitation and prevent the loosening of ACL graft, can lead to better clinical outcomes and kinematics recovery of the knee compared to routine technique.

Biomechanical Evaluation of Suture Tape Internal Brace Reinforcement of Soft Tissue Allografts for ACL Reconstruction Using a Porcine Model

Background:

Internal bracing of anterior cruciate ligament (ACL) surgery is a newer concept gaining popularity.

Purpose/Hypothesis:

To assess the biomechanical performance of soft tissue ACL reconstruction allografts reinforced with suture tape. It was hypothesized that load to failure would increase and cyclic displacement would decrease at time zero in the constructs reinforced with internal brace suture tape compared with those without suture tape augmentation.

Study Design:

Controlled laboratory study.

Methods:

We performed ACL reconstruction on porcine knees using bovine extensor tendon soft tissue allografts: 10 knees without (control) and 10 knees with (reinforced) suture tape reinforcement. An all-inside reconstruction technique was utilized with retrograde tunnel creation. An adjustable-loop device was used for femoral and tibial fixation of all grafts. The suture tape was placed through the tension loop in the femoral fixation construct and independently fixed in the tibia with an interference screw anchor. For each specimen, the authors recorded ultimate load, yield load, stiffness, cyclic displacement, and mode of failure. Outcomes between groups were compared using the Student t test.

Results:

There was a 33% decrease in mean cyclic displacement in the specimens with reinforced grafts (reinforced vs control: 3.9 ± 0.7 vs 5.8 ± 1.5 mm; P = .001). The reinforced grafts also had a 22% higher mean ultimate load (921 ± 180 vs 717 ± 122 N; P = .008) and a 25% higher mean yield load (808 ± 201 vs 602 ± 155 N; P = .020). There was no significant difference in stiffness between the reinforced versus nonreinforced grafts (136 ± 16 vs 132 ± 18 N/mm; P = .617). Three of the 10 control specimens failed at the graft, compared with 1 of 10 reinforced grafts. All other constructs in both groups failed at the tibial fixation site.

Conclusion:

Suture tape reinforcement of soft tissue grafts significantly decreased cyclic displacement while significantly increasing ultimate and yield loads without increasing graft construct stiffness during biomechanical testing at time zero in a porcine animal model.

Clinical Relevance:

The improved biomechanical performance of suture tape–reinforced graft constructs could allow patients to participate in earlier advancement of aggressive rehabilitation and potentially reduce failure rates as graft remodeling progresses.

Suture tape reinforcement of hamstring tendon graft reduces postoperative knee laxity after primary ACL reconstruction

Purpose

To evaluate and compare subjective and objective knee outcomes following hamstring tendon (HT) and quadriceps tendon (QT) anterior cruciate ligament reconstruction (ACLR) with or without suture tape (ST) reinforcement. It was hypothesized that the addition of an intra-articular synthetic augmentation with a ST would reduce postoperative knee laxity and graft ruptures after ACLR.

Methods

A 1:1 matched-cohort comparison of patients who underwent HT and QT autograft ACLR with or without ST reinforcement was performed. Patients with ST reinforcement were consecutively assigned to the study groups until a number of 20 in each group was achieved. Medical records were reviewed for demographic characteristics and additional injuries. Laxity measurements with KT-1000, strength measurements and physical examination findings were collected both preoperatively and at 6 months and patient reported outcome (PRO) scores were collected both preoperatively and at 12 months, and comparison was made HT vs HT + ST and QT vs QT + ST. Reoperations and re-ruptures were recorded during the 24-month follow-up period.

Results

Overall, 80 patients who underwent ACLR were included. Patients with HT + ST had significant less laxity postoperatively compared to HT at 6 months, 1.9 vs 0.8 mm, p < 0.05. No differences were found between the QT and QT + ST group. At 6 weeks patients treated with ST, both QT and HT, had a significant deficit in flexion compared to those without ST. However, this resolved at 6 months. There were no significant differences between HT + ST vs HT, or QT + ST vs QT, regarding postoperative PROs or strength measurements. Furthermore, the incidence of subsequent surgery and graft rupture was not significantly different between the groups.

Conclusion

ACLR with HT + ST reduces laxity at 6 months compared to ACLR without ST, a difference not seen when ACLR was performed using QT with or without ST. No other differences were seen between the two techniques comparing subjective and objective findings.

Level of evidence

Level III.

[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.

All-Inside Anterior Cruciate Ligament Reconstruction with Suture Tape Augmentation: Button Tie-Over Technique (BTOT)

The anterior cruciate ligament (ACL) is the most common ligamentous knee injury in pivoting sports. There are multiple techniques described for ACL reconstruction; however, still there is an ongoing debate regarding the optimal technique with minimal residual laxity and least risk of rerupture. All-inside ACL reconstruction with suture tape augmentation (InternalBrace) is a newly developed method of ACL reconstruction to help address these issues. Suture tape protects the graft during ligamentization process. The aim of this article is to describe a modified all-inside ACL reconstruction technique with suture tape augmentation in which the internal brace is tied distally over the distal TightRope button without an extra method of fixation.

Suspension button constructs restore posterior knee laxity in solid tibial avulsion of the posterior cruciate ligament

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.

Combined Anterior Cruciate Ligament Repair and Anterolateral Ligament Internal Brace Augmentation: Minimum 2-Year Patient-Reported Outcome Measures

Background

The anterolateral ligament (ALL) contributes to anterolateral rotational stability of the knee. Internal bracing of the anterior cruciate ligament (ACL) and ALL reinforces the ligaments and encourages natural healing by protecting both during the healing phase and supporting early mobilization.

Purpose/Hypothesis

To assess the 2-year patient-reported outcomes of combined ACL repair and ALL internal brace augmentation. We hypothesized that significant improvements in outcomes would be seen.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 43 consecutive patients with acute proximal ACL ruptures were prospectively evaluated for a minimum of 2 years. The mean age at the time of surgery was 25.7 years (range, 13-56 years). Indications for the combined ACL/ALL procedure were associated Segond fractures, grade 3 pivot shift, or high levels of sporting activity. Patients with chronic ruptures or with multiligament injuries were excluded. The Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, Veterans RAND 12-Item Health Survey (VR-12), and Marx activity scale were collected preoperatively and at 12 and 24 months postoperatively. Patients with any postoperative complications were identified at the time of this analysis.

Results

The mean follow-up period was 44.8 months. Five patients were lost to follow-up, leaving 38 patients (88.4%) in the final analysis. The mean KOOS for Pain, Symptoms, Activities of Daily Living, Sport/Recreation, and Quality of Life improved from a respective 64.9, 58.6, 75.0, 33.7, and 28.9 preoperatively to 91.1, 81.8, 96.1, 82.8, and 74.3 at the 2-year follow-up (P < .0001). The mean WOMAC scores for pain, stiffness, and function improved from 77.5, 65.3, and 75.0 preoperatively to 94.6, 88.6, and 96.0 at the 2-year follow-up (P < .0001). The VAS pain score improved from 3.4 preoperatively to 0.7 at the 2-year follow-up, and the VR-12 physical score improved from 34.4 preoperatively to 52.7 at the 2-year follow-up (P < .0001 for both ). However, the Marx activity score decreased from 13.3 preinjury to 10.6 at the 2-year follow-up (P = .01). Two patients (5.3%) sustained a rerupture.

Conclusion

Combined ACL repair and ALL internal brace augmentation demonstrated excellent outcomes in 94.7% of the study patients. Based on our experience with this cohort as well as our isolated ACL repair data, we suggest that high-risk patients with ACL ruptures have an additional ALL procedure to provide rotational stability.