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Lavender CD, Schaver AL, Taylor S, Peluso R, Berdis G, Singh V, Cipriani K, Jasko J, Hewett TE. 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. Arthroscopy 2024:S0749-8063(24)00492-4. [PMID: 39047990 DOI: 10.1016/j.arthro.2024.06.042] [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] [Received: 11/26/2023] [Revised: 06/14/2024] [Accepted: 06/27/2024] [Indexed: 07/27/2024]
Abstract
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.
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Affiliation(s)
- Chad D Lavender
- Marshall University, Department of Orthopedic Surgery 1600 Medical Center Dr. Huntington, WV 25701.
| | - Andrew L Schaver
- Marshall University, Department of Orthopedic Surgery 1600 Medical Center Dr. Huntington, WV 25701
| | - Shane Taylor
- Marshall University, Department of Orthopedic Surgery 1600 Medical Center Dr. Huntington, WV 25701
| | - Richard Peluso
- Marshall University, Department of Orthopedic Surgery 1600 Medical Center Dr. Huntington, WV 25701
| | - Galen Berdis
- Marshall University, Department of Orthopedic Surgery 1600 Medical Center Dr. Huntington, WV 25701
| | - Vishapreet Singh
- Marshall University, Department of Orthopedic Surgery 1600 Medical Center Dr. Huntington, WV 25701
| | - Kara Cipriani
- Marshall University, Department of Orthopedic Surgery 1600 Medical Center Dr. Huntington, WV 25701
| | - John Jasko
- Marshall University, Department of Orthopedic Surgery 1600 Medical Center Dr. Huntington, WV 25701
| | - Timothy E Hewett
- Marshall University, Department of Orthopedic Surgery 1600 Medical Center Dr. Huntington, WV 25701
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Levin SA, Reed LA, Levy BA. Editorial Commentary: Clinical and Basic Science Evidence Supports the Use of Suture Tape Augmentation of Posterior Cruciate Ligament Reconstruction. Arthroscopy 2024; 40:2055-2057. [PMID: 38428699 DOI: 10.1016/j.arthro.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/03/2024]
Abstract
Although isolated posterior cruciate ligament (PCL) injuries often can be treated successfully without surgical intervention, in the setting of persistent instability or multiligamentous knee injury, PCL reconstruction is indicated. PCL reconstructions often have resulted in persistent postoperative laxity. Recent research suggests there may be a role for suture tape-augmented grafts, which have demonstrated decreased clinical and radiographic laxity as well as improved rates of return to previous level of activity, as compared with PCL reconstruction alone. Several biomechanical studies also have supported the use of suture tape augmentation in PCL reconstruction, and the use of suture tape augmentation or internal bracing and ligament surgery is gaining widespread popularity. These ultrahigh molecular weight polyethylene/polyester suture tapes have been shown to be safe and effective. We may be at the point at which the evidence supports the use of suture tape augmentation of PCL reconstruction.
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Affiliation(s)
- Samantha A Levin
- Orlando Health Jewett Orthopedic Institute, Orlando, Florida, U.S.A
| | - Logan A Reed
- Orlando Health Jewett Orthopedic Institute, Orlando, Florida, U.S.A
| | - Bruce A Levy
- Orlando Health Jewett Orthopedic Institute, Orlando, Florida, U.S.A
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Quinn M, Lemme N, Morrissey P, Fadale P, Owens BD. An Update on Emerging Techniques and Considerations in Revision Anterior Cruciate Ligament Reconstruction. JBJS Rev 2024; 12:01874474-202407000-00007. [PMID: 39018384 DOI: 10.2106/jbjs.rvw.24.00047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
» The rate of primary anterior cruciate ligament reconstruction (ACLR) failure in at-risk populations remains unacceptably high and necessitates thorough evaluation of native alignment and concomitant injuries.» Posterior tibial slope of >12° is a substantial risk factor of ACLR failure and should be corrected through anterior closing wedge osteotomy.» Varus malalignment of >5° exacerbates stress on the ACL graft, increases ACLR failure risks, and should be considered for correction through high tibial osteotomy at the time of revision ACLR.» Injuries to the anterolateral ligamentous complex are prevalent in ACL ruptures, and high-risk patients have shown benefit from anterolateral ligament reconstruction or lateral extra-articular tenodesis in the revision setting.» Addressing posterolateral corner, collateral ligament, and meniscal injuries, during revision ACLR, is vital to mitigate increased graft forces and optimize knee stability and functional outcomes.
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Affiliation(s)
- Matthew Quinn
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Rupp MC, Winkler PW, Willinger L, Runer A. Editorial Commentary: Early Outcomes of Suture Tape Augmentation in Quadriceps Tendon Autograft Anterior Cruciate Ligament Reconstruction Are Promising but Require Long-term Proof. Arthroscopy 2024:S0749-8063(24)00328-1. [PMID: 38705543 DOI: 10.1016/j.arthro.2024.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Accepted: 04/29/2024] [Indexed: 05/07/2024]
Abstract
The management of anterior cruciate ligament (ACL) injuries continually evolves, with new interest in all-soft tissue quadriceps tendon autograft, as well as new interest in suture tape augmentation of the graft, particularly in high-risk patients with young age; female sex; lower-limb alignment, tibial, or femoral abnormalities; hyperlaxity; concomitant meniscal and/or additional ligamentous injuries; or participation in high-risk sports. Load-sharing suture tape enhances the biomechanical stability of the reconstructed ACL, especially during the initial ingrowth and ligamentization phase, and biomechanical evidence highlights a reduced risk of graft elongation and failure under the loads encountered during daily physical activities and sport. Optimal tape tensioning could be achieved in knee hyperextension, when the ACL is at maximal length, to avoid overconstraint. The published 2-year outcomes of this technique are excellent. Current comparative studies, however, have not shown superiority. Additional controlled studies and studies with longer-term follow-up are needed, as well as comparison to extra-articular tenodesis augmentation.
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Affiliation(s)
| | | | | | - Armin Runer
- Technical University of Munich (P.W.W., L.W., A.R.)
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Daniel AV, Smith PA. 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. Arthroscopy 2024:S0749-8063(24)00234-2. [PMID: 38518869 DOI: 10.1016/j.arthro.2024.02.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 03/24/2024]
Abstract
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.
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Affiliation(s)
- Adam V Daniel
- Columbia Orthopaedic Group, Columbia, Missouri, U.S.A..
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Mackay GM, Wilson WT, Hopper GP. Editorial Commentary: Anterior Cruciate Ligament Repair or Reconstruction With Internal Bracing, for Properly Indicated Patients, Is Safe, Biocompatible, and Biomimetic. Arthroscopy 2024:S0749-8063(24)00202-0. [PMID: 38499115 DOI: 10.1016/j.arthro.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 03/20/2024]
Abstract
Anterior cruciate ligament (ACL) reconstruction with internal bracing (IB)-and ACL repair with IB when indicated-reduces graft or repair failure. IB is safe and protects ligament reconstructions and repairs. The IB construct should not be misunderstood as a synthetic ligament. To be effective, suture tape must be independently secured with the knee in full extension, reflecting the terminal length of the ACL. Regardless of graft type, the graft must be cyclically tensioned independent of the IB to allow for creep, and when properly performed, this significantly increases the ultimate tensile strength of the construct and reduces graft elongation, without stress shielding. Thus, the generic term "suture augmentation" may be misleading because the successful results reported apply to the IB technique. In our experience, the failure rate after ACL reconstruction with IB is 1% at the 5-year follow-up period. Notably, these results were achieved without an additional lateral extra-articular procedure.
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Klein B, Bartlett LE, Huyke-Hernandez FA, Tauro TM, Landman F, Cohn RM, Sgaglione NA. Analysis of Changing Practice Trends in Anterior Cruciate Ligament Reconstruction: A Multicenter, Single-Institution Database Analysis. Arthroscopy 2024:S0749-8063(24)00169-5. [PMID: 38447628 DOI: 10.1016/j.arthro.2024.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 02/24/2024] [Accepted: 02/24/2024] [Indexed: 03/08/2024]
Abstract
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.
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Affiliation(s)
- Brandon Klein
- Department of Orthopaedic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Huntington, New York, U.S.A..
| | - Lucas E Bartlett
- Rowan-Virtua School of Osteopathic Medicine, Stratford, New Jersey, U.S.A
| | | | - Tracy M Tauro
- Rowan-Virtua School of Osteopathic Medicine, Stratford, New Jersey, U.S.A
| | - Francis Landman
- Mount Sinai South Nassau, Department of Internal Medicine, Oceanside, New York, U.S.A
| | - Randy M Cohn
- Department of Orthopaedic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Huntington, New York, U.S.A
| | - Nicholas A Sgaglione
- Department of Orthopaedic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Huntington, New York, U.S.A
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Dhillon J, Tanguilig G, Keeter C, Borque KA, Heard WM, Kraeutler MJ. Insufficient Evidence for Anterior Cruciate Ligament Reconstruction Utilizing Suture Tape Augmentation: A Systematic Review of Clinical Outcomes at Minimum 1-Year Follow-up. Arthroscopy 2024:S0749-8063(24)00070-7. [PMID: 38309447 DOI: 10.1016/j.arthro.2024.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/09/2024] [Accepted: 01/12/2024] [Indexed: 02/05/2024]
Abstract
PURPOSE To perform a systematic review of clinical studies to directly compare clinical outcomes of patients undergoing anterior cruciate ligament reconstruction (ACLR) with versus without suture tape (ST) augmentation. METHODS A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify comparative studies directly comparing outcomes of ACLR with versus without ST augmentation with a minimum follow-up of 12 months. The search terms used were anterior cruciate ligament suture tape. Patients were evaluated based on graft failure rates, return to sport (RTS), anteroposterior (AP) laxity, and patient-reported outcomes (PROs). RESULTS Five studies (all Level III) met inclusion criteria, including a total of 246 patients undergoing ACLR with ST augmentation (SA group) and 282 patients undergoing ACLR without augmentation (control group). Patient age ranged from 14.9 to 29.7 years. The mean follow-up time ranged from 24.0 to 48.6 months. The mean body mass index ranged from 25.3 to 26.3 kg/m2 and the overall percentage of males ranged from 43.4% to 69.0%. Overall, the graft failure rate ranged from 1.0% to 25.0% in the SA group and 8.0% to 20.0% in the control group. Among the studies that reported RTS rates, the rate ranged from 69.2% to 88.9% in the SA group and 51.5% to 87.5% in the control group. Among all PROs, 2 studies found a significant difference in the Tegner score favoring the SA group. Otherwise, no significant differences were found between groups in terms of PROs. No significant differences in AP laxity were found between groups within any particular study. There was heterogeneity between studies regarding surgical techniques, postoperative rehabilitation protocols, and reported PROs. CONCLUSIONS There is insufficient evidence to suggest that patients undergoing ACLR with ST augmentation may experience favorable clinical outcomes compared with ACLR alone. LEVEL OF EVIDENCE Level III, systematic review of Level III studies.
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Affiliation(s)
- Jaydeep Dhillon
- Rocky Vista University College of Osteopathic Medicine, Parker, Colorado, U.S.A
| | - Grace Tanguilig
- Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Carson Keeter
- Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A
| | - Kyle A Borque
- Department of Orthopedics & Sports Medicine, Houston Methodist Hospital, Houston, Texas, U.S.A
| | - Wendell M Heard
- Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Matthew J Kraeutler
- Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A..
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