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Fleming BC, Baranker B, Badger GJ, Kiapour AM, Ecklund K, Micheli LJ, Murray MM. Bridge-Enhanced Anterior Cruciate Ligament Restoration: 6-Year Results From the First-in-Human Cohort Study. Orthop J Sports Med 2024; 12:23259671241260632. [PMID: 39143986 PMCID: PMC11322937 DOI: 10.1177/23259671241260632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/02/2024] [Indexed: 08/16/2024] Open
Abstract
Background Bridge-enhanced anterior cruciate ligament restoration (BEAR) combines suture repair of the anterior cruciate ligament (ACL) with an extracellular matrix implant plus autologous blood to facilitate native ACL healing. Purpose/Hypothesis The purpose of this study was to compare the 6-year follow-up outcomes of patients who underwent the BEAR procedure with those of a nonrandomized concurrent control group receiving autograft ACL reconstruction (ACLR) in the first-in-human safety study of the BEAR implant (BEAR I trial). Based on the 2-year results, it was hypothesized that isometric hamstring strength after the BEAR procedure would be greater than that after ACLR and that there would be no other differences in outcomes at 6 years. Study Design Cohort study, Level of evidence, 2. Methods Ten patients underwent BEAR and 10 received ACLR with a 4-stranded hamstring autograft. Outcomes assessed included the record of subsequent surgeries, the International Knee Documentation Committee (IKDC) Subjective Knee Score, IKDC physical examination grade, the Knee injury and Osteoarthritis Outcome Score, instrumented knee laxity, functional outcomes (ie, muscle strength assessments and hop testing), and qualitative magnetic resonance imaging assessment. Comparisons between treatments were based on computations of the mean differences and the associated 95% CIs. Results One patient in the BEAR group and 3 patients in the ACLR group were lost to follow-up. In the period between 2 and 6 years, 1 patient in each group underwent revision surgery. There were no differences between groups at the 6-year follow-up in any of the outcome measures except for isometric hamstring strength, which was approximately equal to that of the contralateral knee in the BEAR group and <44% of that in the contralateral knee in the ACLR group (P < .01). Conclusion This preliminary study suggests that the outcomes of BEAR and ACLR with a hamstring tendon graft may be similar at the 6-year follow-up and warrants investigation of the BEAR procedure in a larger cohort of patients.
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Affiliation(s)
- Braden C. Fleming
- Department of Orthopaedics, Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Ben Baranker
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Gary J. Badger
- Department of Medical Biostatistics, University of Vermont, Burlington, Vermont, USA
| | - Ata M. Kiapour
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kirsten Ecklund
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle J. Micheli
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Martha M. Murray
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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Rilk S, Goodhart GC, van der List JP, Von Rehlingen-Prinz F, Vermeijden HD, O'Brien R, DiFelice GS. Anterior cruciate ligament primary repair revision rates are increased in skeletally mature patients under the age of 21 compared to reconstruction, while adults (>21 years) show no significant difference: A systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38967267 DOI: 10.1002/ksa.12239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/21/2024] [Accepted: 04/26/2024] [Indexed: 07/06/2024]
Abstract
PURPOSE To evaluate the impact of age as a risk factor on the revision rates of anterior cruciate ligament (ACL) primary repair (ACLPR), dynamic intraligamentary stabilization (DIS) and bridge-enhanced ACL restoration (BEAR) compared to ACL reconstruction (ACLR). METHODS A systematic literature search was performed for comparative studies comparing outcomes for ACLPR, DIS or BEAR to ACLR. A random-effects meta-analysis was performed to assess nondifferentiated and age-differentiated (skeletally mature patients ≤21 and >21 years) ACL revision and reoperation risk, as well as results for subjective outcomes. Methodological study quality was assessed using the Risk of Bias Tool 2.0c and Methodological Index for Nonrandomized Studies tools. RESULTS A total of 12 studies (n = 1277) were included. ACLR demonstrated a lower nonage-stratified revision risk at 2 years versus ACLPR, DIS and BEAR, but a similar revision risk at 5 years when compared to DIS. However, an age-stratified analysis demonstrated a significantly increased ACLPR revision risk as compared to ACLR in skeletally mature patients ≤21 years of age (risk ratios [RR], 6.33; 95% confidence interval [CI], 1.18-33.87, p = 0.03), while adults (>21 years) showed no significant difference between groups (RR, 1.48; 95% CI, 0.25-8.91, n.s.). Furthermore, DIS reoperation rates were significantly higher than respective ACLR rates (RR, 2.22; 95% CI, 1.35-3.65, p = 0.002), whereas BEAR (RR, 1.07; 95% CI, 0.41-2.75, n.s.) and ACLPR (RR, 0.81; 95% CI, 0.21-3.09, n.s.) showed no differences. IKDC scores were equivalent for all techniques. However, ACLPR exhibited significantly better FJS (mean difference, 11.93; 95% CI, 6.36-17.51, p < 0.0001) and Knee injury and Osteoarthritis Outcome Score Symptoms (mean difference, 3.01; 95% CI, 0.42-5.60, p = 0.02), along with a lower Tegner activity reduction. CONCLUSIONS ACLPR in skeletally mature patients ≤21 years of age is associated with up to a six-fold risk increase for ACL revision surgery compared to ACLR; however, adults (>21 years) present no significant difference. Based on the current data, age emerges as a crucial risk factor and should be considered when deciding on the appropriate treatment option in proximal ACL tears. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Sebastian Rilk
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York-Presbyterian, Weill Medical College of Cornell University, New York, New York, USA
- Medical University of Vienna, Vienna, Austria
| | - Gabriel C Goodhart
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York-Presbyterian, Weill Medical College of Cornell University, New York, New York, USA
| | - Jelle P van der List
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York-Presbyterian, Weill Medical College of Cornell University, New York, New York, USA
- Department of Orthopaedic Surgery, Atrium Health Wake Forest Baptist, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Fidelius Von Rehlingen-Prinz
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York-Presbyterian, Weill Medical College of Cornell University, New York, New York, USA
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Harmen D Vermeijden
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York-Presbyterian, Weill Medical College of Cornell University, New York, New York, USA
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Robert O'Brien
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York-Presbyterian, Weill Medical College of Cornell University, New York, New York, USA
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Gregory S DiFelice
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York-Presbyterian, Weill Medical College of Cornell University, New York, New York, USA
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Bixby EC, Heyworth BE. Management of Anterior Cruciate Ligament Tears in Skeletally Immature Patients. Curr Rev Musculoskelet Med 2024; 17:258-272. [PMID: 38639870 PMCID: PMC11156825 DOI: 10.1007/s12178-024-09897-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2024] [Indexed: 04/20/2024]
Abstract
PURPOSE OF REVIEW Anterior cruciate ligament (ALC) tears are increasingly common in skeletally immature patients, as more children and adolescents participate in intensive sports training and specialization at increasingly younger ages. These injuries were historically treated nonoperatively, given concerns for physeal damage and subsequent growth disturbances after traditional ACL reconstruction techniques. However, there is now sufficient data to suggest superior outcomes with operative treatment, specifically with physeal-sparing and physeal-respecting techniques. This article reviews considerations of skeletal maturity in patients with ACL tears, then discusses surgical techniques, with a focus on their unique indications and outcomes. Additional surgical adjuncts and components of postoperative rehabilitation, which may reduce retear rates, are also considered. RECENT FINDINGS Current research shows favorable patient-reported outcomes and high return-to-sport rates after ACL reconstruction in skeletally immature patients. Graft rupture (ACL retear) rates are low, but notably higher than in most adult populations. Historically, there has been insufficient research to comprehensively compare reconstruction techniques used in this patient population. However, thoughtful systematic reviews and multicenter prospective studies are emerging to address this deficit. Also, more recent data suggests the addition of lateral extra-articular procedures and stringent return-to-sports testing may lower retear rates. Physeal-sparing and physeal-respecting ACL reconstructions result in stabilization of the knee, while respecting the growth remaining in children or skeletally immature adolescents. Future research will be essential to compare these techniques, given that more than one may be appropriate for patients of a specific age and skeletal maturity.
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Affiliation(s)
- Elise C Bixby
- Department of Sports Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Benton E Heyworth
- Department of Sports Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
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Gao S, Wang T. Suture Anchor Technique for Bridge Enhanced Anterior Cruciate Ligament Restoration. Arthrosc Tech 2024; 13:102880. [PMID: 38584620 PMCID: PMC10995693 DOI: 10.1016/j.eats.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 11/02/2023] [Indexed: 04/09/2024] Open
Abstract
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.
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Affiliation(s)
- Sean Gao
- Department of Orthopaedic Surgery, Sports Medicine, Scripps Clinic Medical Group, La Jolla, California, U.S.A
| | - Tim Wang
- Department of Orthopaedic Surgery, Sports Medicine, Scripps Clinic Medical Group, La Jolla, California, U.S.A
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Flannery SW, Beveridge JE, Proffen BL, Walsh EG, Kramer DE, Murray MM, Kiapour AM, Fleming BC. Predicting anterior cruciate ligament failure load with T 2* relaxometry and machine learning as a prospective imaging biomarker for revision surgery. Sci Rep 2023; 13:3524. [PMID: 36864112 PMCID: PMC9981601 DOI: 10.1038/s41598-023-30637-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 02/27/2023] [Indexed: 03/04/2023] Open
Abstract
Non-invasive methods to document healing anterior cruciate ligament (ACL) structural properties could potentially identify patients at risk for revision surgery. The objective was to evaluate machine learning models to predict ACL failure load from magnetic resonance images (MRI) and to determine if those predictions were related to revision surgery incidence. It was hypothesized that the optimal model would demonstrate a lower mean absolute error (MAE) than the benchmark linear regression model, and that patients with a lower estimated failure load would have higher revision incidence 2 years post-surgery. Support vector machine, random forest, AdaBoost, XGBoost, and linear regression models were trained using MRI T2* relaxometry and ACL tensile testing data from minipigs (n = 65). The lowest MAE model was used to estimate ACL failure load for surgical patients at 9 months post-surgery (n = 46) and dichotomized into low and high score groups via Youden's J statistic to compare revision incidence. Significance was set at alpha = 0.05. The random forest model decreased the failure load MAE by 55% (Wilcoxon signed-rank test: p = 0.01) versus the benchmark. The low score group had a higher revision incidence (21% vs. 5%; Chi-square test: p = 0.09). ACL structural property estimates via MRI may provide a biomarker for clinical decision making.
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Affiliation(s)
- Sean W Flannery
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Coro West, Suite 402, 1 Hoppin St, Providence, RI, 02903, USA
| | - Jillian E Beveridge
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Coro West, Suite 402, 1 Hoppin St, Providence, RI, 02903, USA
| | - Benedikt L Proffen
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward G Walsh
- Department of Neuroscience, Division of Biology and Medicine, Brown University, Providence, RI, USA
| | - Dennis E Kramer
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Martha M Murray
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ata M Kiapour
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Braden C Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Coro West, Suite 402, 1 Hoppin St, Providence, RI, 02903, USA.
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Barnes DA, Flannery SW, Badger GJ, Yen YM, Micheli LJ, Kramer DE, Fadale PD, Hulstyn MJ, Owens BD, Murray MM, Fleming BC, Kiapour AM. Quantitative MRI Biomarkers to Predict Risk of Reinjury Within 2 Years After Bridge-Enhanced ACL Restoration. Am J Sports Med 2023; 51:413-421. [PMID: 36645042 PMCID: PMC9905304 DOI: 10.1177/03635465221142323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Quantitative magnetic resonance imaging (qMRI) methods were developed to establish the integrity of healing anterior cruciate ligaments (ACLs) and grafts. Whether qMRI variables predict risk of reinjury is unknown. PURPOSE To determine if qMRI measures at 6 to 9 months after bridge-enhanced ACL restoration (BEAR) can predict the risk of revision surgery within 2 years of the index procedure. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Originally, 124 patients underwent ACL restoration as part of the BEAR I, BEAR II, and BEAR III prospective trials and had consented to undergo an MRI of the surgical knee 6 to 9 months after surgery. Only 1 participant was lost to follow-up, and 4 did not undergo MRI, leaving a total of 119 patients for this study. qMRI techniques were used to determine the mean cross-sectional area; normalized signal intensity; and a qMRI-based predicted failure load, which was calculated using a prespecified equation based on cross-sectional area and normalized signal intensity. Patient-reported outcomes (International Knee Documentation Committee subjective score), clinical measures (hamstring strength, quadriceps strength, and side-to-side knee laxity), and functional outcomes (single-leg hop) were also measured at 6 to 9 months after surgery. Univariate and multivariable analyses were performed to determine the odds ratios (ORs) for revision surgery based on the qMRI and non-imaging variables. Patient age and medial posterior tibial slope values were included as covariates. RESULTS In total, 119 patients (97%), with a median age of 17.6 years, underwent MRI between 6 and 9 months postoperatively. Sixteen of 119 patients (13%) required revision ACL surgery. In univariate analyses, higher International Knee Documentation Committee subjective score at 6 to 9 months postoperatively (OR = 1.66 per 10-point increase; P = .035) and lower qMRI-based predicted failure load (OR = 0.66 per 100-N increase; P = .014) were associated with increased risk of revision surgery. In the multivariable model, when adjusted for age and posterior tibial slope, the qMRI-based predicted failure load was the only significant predictor of revision surgery (OR = 0.71 per 100 N; P = .044). CONCLUSION Quantitative MRI-based predicted failure load of the healing ACL was a significant predictor of the risk of revision within 2 years after BEAR surgery. The current findings highlight the potential utility of early qMRI in the postoperative management of patients undergoing the BEAR procedure.
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Affiliation(s)
- Dominique A. Barnes
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Sean W. Flannery
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Gary J. Badger
- Department of Medical Biostatistics, Larner College of
Medicine, University of Vermont, Burlington, VT, USA
| | - Yi-Meng Yen
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Lyle J. Micheli
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Dennis E. Kramer
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Paul D. Fadale
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Michael J. Hulstyn
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Brett D. Owens
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Martha M. Murray
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Ata M. Kiapour
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
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