Paediatric ACL repair reinforced with temporary internal bracing

Context: Injury to the anterior cruciate ligament (ACL) is among the most common orthopaedic injuries, and reconstruction of a ruptured ACL is a common orthopaedic procedure. In general, surgical intervention is necessary to restore stability to the injured knee, and to prevent meniscal damage. Along with surgery, intense postoperative physical therapy is needed to restore function to the injured extremity. ACL reconstruction (ACLR) has been the standard of care in recent decades, and advances in surgical technology have reintroduced the prospect of augmented primary repair of the native ACL via a variety of methods. Evidence Acquisition: A search of PubMed database of articles and reviews available in English was performed through 2020. The search terms ACLR, anterior cruciate ligament repair, bridge enhanced acl repair, suture anchor repair, dynamic intraligamentary stabilization, internal bracing, suture ligament augmentation, and internal brace ligament augmentation were used. Study Design: Clinical review. Level of Evidence: Level 5. Results: No exact consensus exists on effective rehabilitation protocols after ACL repair techniques, as the variation in published protocols seem even greater than the variation in those for ACLR. For some techniques such as internal bracing and dynamic interligamentary stabilization, it is likely permissible for the patients to progress to full weightbearing and discontinue bracing sooner. However, caution should be applied with regard to earlier return to sport than after ACLR as to minimize risk for retear. Conclusion: More research is needed to address how physical therapies must adapt to these innovative repair techniques. Until that is accomplished, we recommend that physical therapists understand the differences among the various ACL surgery techniques discussed here and work with the surgeons to develop a rehabilitation protocol for their mutual patients. Strength of Recommendation Taxonomy (SORT): C.

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Is There a Role for Internal Bracing and Repair of the Anterior Cruciate Ligament? A Systematic Literature Review

The American Journal of Sports Medicine ◽

10.1177/0363546517717956 ◽

2017 ◽

Vol 46 (9) ◽

pp. 2291-2298 ◽

Cited By ~ 46

Author(s):

Carola F. van Eck ◽

Orr Limpisvasti ◽

Neal S. ElAttrache

Keyword(s):

Anterior Cruciate Ligament ◽

Success Rate ◽

Platelet Rich Plasma ◽

Primary Repair ◽

Cruciate Ligament ◽

Young Patients ◽

Acl Repair ◽

Internal Bracing ◽

Electronic Database Search ◽

Anterior Cruciate

Background: Renewed interest has arisen in arthroscopic anterior cruciate ligament (ACL) repair techniques. Hypothesis: ACL repair with or without some form of internal bracing could lead to good outcomes in a carefully selected subset of patients. Study Design: Systematic review. Methods: An electronic database search was performed to identify 89 papers describing preclinical and clinical studies on the outcome of ACL repair. Results: Proximal ACL tear patterns showed a better healing potential with primary repair than distal or midsubstance tears. Some form of internal bracing increased the success rate of ACL repair. Improvement in the biological characteristics of the repair was obtained by bone marrow access by drilling tunnels or microfracture. Augmentation with platelet-rich plasma was beneficial only in combination with a structural scaffold. Skeletally immature patients had the best outcomes. Acute repair offered improved outcomes with regard to load, stiffness, laxity, and rerupture. Conclusion: ACL repair may be a viable option in young patients with acute, proximal ACL tears. The use of internal bracing, biological augmentation, and scaffold tissue may increase the success rate of repair.

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The Comparison of Clinical Result between Primary Repair of the Anterior Cruciate Ligament with Additional Internal Bracing and Anatomic Single Bundle Reconstruction—A Retrospective Study

Journal of Clinical Medicine ◽

10.3390/jcm10173948 ◽

2021 ◽

Vol 10 (17) ◽

pp. 3948

Author(s):

Dawid Szwedowski ◽

Łukasz Paczesny ◽

Jan Zabrzyński ◽

Maciej Gagat ◽

Marcin Domżalski ◽

...

Keyword(s):

Primary Repair ◽

Cruciate Ligament ◽

Anterior Tibial Translation ◽

Single Bundle ◽

Acl Repair ◽

Anterior Tibial ◽

Internal Bracing ◽

Anterior Cruciate ◽

Tibial Translation ◽

Repair Group

Background: The current standard of treatment of anterior cruciate ligament (ACL) is reconstruction (ACLR). This technique has some disadvantages: poor proprioception, donor site morbidity and the inability to restore joint kinematics. ACL repair could be an alternative treatment. The purpose of the study was to compare the stability and the function after ACL primary repair versus single-bundle ACLR. Methods: In a retrospective study, 12 patients underwent primary ACL repair with internal bracing, 15 patients underwent standard ACLR. Follow-up examinations were evaluated at up to 2 years postoperatively. One patient in the ACL repair group was lost to follow-up due to re-rupture. The absolute value of anterior tibial translation (ATT) and the side-to-side difference in the same patient (ΔATT) were evaluated using the GNRB arthrometer. The Lysholm knee scoring was obtained. Re-ruptures and other complications were recorded. Results: Anterior tibial translation (ATT) was significantly decreased in the ACL repair group compared with the ACLR group (5.31 mm vs. 7.18 mm, respectively; p = 0.0137). Arthrometric measurements demonstrated a mean side-to-side difference (ΔATT) 1.87 (range 0.2 to 4.9) mm significantly decreased compared to ACLR 3.36 (range 1.2–5.6 mm; p = 0.0107). The mean Lysholm score was 85.3 points in the ACL repair group and 89.9 in ACLR group. No significant differences between ACL repair and ACLR were found for the Lysholm score. There was no association between AP laxity and clinical outcomes. There were two complications in the internal bracing group: one patient had re-rupture and was treated by ACLR, another had limited extension and had arthroscopic debridement. Conclusions: Anterior tibial translation was significantly decreased after ACL repair. Additionally, the functional results after ACL repair with internal bracing were comparable with those after ACLR. It should be noted that the two complications occurred. The current study supports further development of ACL repair techniques.

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Anterior cruciate ligament – to repair or not to repair?

Chirurgia Narządów Ruchu i Ortopedia Polska ◽

10.31139/chnriop.2021.86.2.5 ◽

2020 ◽

Vol 86 (2) ◽

pp. 59-65

Author(s):

Piotr Wodziński ◽

◽

Andrzej Wielgus ◽

Łukasz Mucha ◽

Tomasz Mazurek ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Cruciate Ligament ◽

Sport Activity ◽

Return To Sport ◽

Acl Injury ◽

Actual State ◽

Type I ◽

Acl Repair ◽

Internal Bracing ◽

Anterior Cruciate

Anterior cruciate ligament injuries are one of the most frequent knee joint injuries, leading to instability which limits return to sport activity, and is one of osteoarthritis risk factors. Treatment issues are present since 1895, when Mayo Robertson performed first documented open ACL repair. Positive short-term results of open suturing led to rising popularity of this method, which in 70’s and 80’s became golden standard of ACL injury treatment. Feagin in his longterm observations noticed that nearly half of patients after open ACL repair, during first 5 years suffered from reappearing ACL tear. Since then, for many years reconstruction techniques with graft use became most popular technique. Increasing knowledge of ligament healing biology, creation of Sherman’s ACL injury location classification, development of arthroscopic techniques, connected with growing tendency for biological treatment caused increase in repair techniques interest. Most important potential benefits of this techniques are: limitation of perioperative trauma – no need to harvest graft, drill large tunnels, possible retention of additional ACL proprioceptive feeling, easier eventual reoperation. Effort to save patient’s ACL is especially indicated in case of acute trauma (depending on source up to 3-14 weeks from injury), with proximal tear (type I in Sherman classification) with good remnant quality. Most popular techniques of ACL repair are: proximal ACL attachment reinsertion, IBLA – Internal Bracing Ligament Augmentation and DIS – Dynamic Intraligamentary Stabilization. The aim of this study was to present actual state of knowledge concerning options of primary ACL repair, it’s results, indications, and sharing authors own experiences in this treatment methods. Preliminary, available in literature, results of studies concerning methods mentioned above are good and very good, comparable, and sometimes even superior to results of classical ACL reconstruction. However, there is lack of long-term studies, that might confirm increase in survivorship rate of repaired ACLs comparing to previous open suturing technique.

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Treatment of Acute Proximal Anterior Cruciate Ligament Tears—Part 2: The Role of Internal Bracing on Gap Formation and Stabilization of Repair Techniques

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119897423 ◽

2020 ◽

Vol 8 (1) ◽

pp. 232596711989742 ◽

Cited By ~ 2

Author(s):

Samuel Bachmaier ◽

Gregory S. DiFelice ◽

Bertrand Sonnery-Cottet ◽

Wiemi A. Douoguih ◽

Patrick A. Smith ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Cruciate Ligament ◽

Analysis Of Covariance ◽

Gap Formation ◽

Acl Repair ◽

Peak Loads ◽

Internal Bracing ◽

Internal Brace ◽

Anterior Cruciate ◽

Repair Techniques

Background: The latest biomechanical studies on some form of internal bracing have shown improved stabilization for anterior cruciate ligament (ACL) repair, but gap formation and load-sharing function have not yet been reported. Hypothesis: Internal bracing of an adjustable ACL repair construct provides improved stabilization with reduced gap formation and higher residual loading on the ACL. Study Design: Controlled laboratory study. Methods: Internally braced ACL repair constructs with single– and double–cinch loop (CL) cortical buttons, a knotless suture anchor, and a single-CL cortical button with adjustable loop fixation (CLS-ALD) were tested (n = 20 each) in a porcine model at 4 different loads (n = 5 each) over 4000 cycles at 0.75 Hz (n = 80 total). The CLS-ALD technique allowed for additional preconditioning (10 cycles at 0.5 Hz). Test results of the isolated internal brace groups served as a baseline for comparison. Lastly, specimens were pulled to failure (50 mm/min) with a cut internal brace. Final loading and gap formation on the ACL repair construct as well as ultimate strength were analyzed. Results: A statistical significance for peak loads over peak elongation was found between the CLS-ALD and all other reinforced groups (analysis of covariance, P < .001). Accordingly, the adjustable repair technique showed improved load-bearing capability with the internal brace compared with all other fixed repair groups and revealed significantly higher loads than the knotted single-CL group. Also, significantly reduced gap formation was found for the CLS-ALD compared with all other groups ( P < .001), with no gap formation up to 150 N with a final gap of 0.85 ± 0.31 mm at 350 N. A significantly higher ultimate failure load (866.2 ± 104.0 N; P < .001) was found for the button-fixed internal brace group compared with all other groups. Conclusion: Internal bracing had a crucial role in improving the stabilization potential of ACL repair at loads occurring during normal daily activity. The added strength of the internal brace allowed for reducing peak loads on the ACL repair construct as well as restricting gap formation to below 3 mm at loads up to 350 N. Clinical Relevance: Improvements in the mechanical characteristics of current ACL repair techniques that enable reduced gap formation and allow for early range of motion and accelerated rehabilitation may strengthen the self-healing response with the formation of stable scar tissue.

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Suture tape augmentation ACL repair, stable knee, and favorable PROMs, but a re-rupture rate of 11% within 2 years

Knee Surgery Sports Traumatology Arthroscopy ◽

10.1007/s00167-020-06399-2 ◽

2021 ◽

Author(s):

Christiaan H. W. Heusdens ◽

Karen Blockhuys ◽

Ella Roelant ◽

Lieven Dossche ◽

Francis Van Glabbeek ◽

...

Keyword(s):

Acl Repair ◽

Rupture Rate ◽

Suture Tape

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Satisfactory patient-reported outcomes at 5 years following primary repair with suture tape augmentation for proximal anterior cruciate ligament tears

Knee Surgery Sports Traumatology Arthroscopy ◽

10.1007/s00167-021-06485-z ◽

2021 ◽

Author(s):

Graeme P. Hopper ◽

Joanna M. S. Aithie ◽

Joanne M. Jenkins ◽

William T. Wilson ◽

Gordon M. Mackay

Keyword(s):

Anterior Cruciate Ligament ◽

Patient Reported Outcomes ◽

Primary Repair ◽

Cruciate Ligament ◽

Acl Repair ◽

Patient Reported ◽

Activity Scale ◽

Anterior Cruciate ◽

Suture Tape

Abstract Purpose An enhanced understanding of anterior cruciate ligament (ACL) healing and advancements in arthroscopic instrumentation has resulted in a renewed interest in ACL repair. Augmentation of a ligament repair with suture tape reinforces the ligament and acts as a secondary stabilizer. This study assesses the 5-year patient-reported outcomes of primary repair with suture tape augmentation for proximal ACL tears. Methods Thirty-seven consecutive patients undergoing ACL repair with suture tape augmentation for an acute proximal rupture were prospectively followed up for a minimum of 5 years. Patients with midsubstance and distal ruptures, poor ACL tissue quality, retracted ACL remnants and multiligament injuries were excluded. Patient-reported outcome measures were collated using the Knee Injury and Osteoarthritis Outcomes Score (KOOS), Visual Analogue Pain Scale (VAS-pain), Veterans RAND 12-Item Health Survey (VR-12) and the Marx Activity Scale. Patients with a re-rupture were identified. Results Three patients were lost to follow-up leaving 34 patients in the final analysis (91.9%). The mean KOOS at 5 years was 88.5 (SD 13.8) which improved significantly from 48.7 (SD 18.3) preoperatively (p < 0.01). The VAS score improved from 2.3 (SD 1.7) to 1.0 (SD 1.5) and the VR-12 score improved from 35.9 (SD 10.3) to 52.4 (SD 5.9) at 5 years (p < 0.01). However, the Marx activity scale decreased from 12.4 (SD 3.4) pre-injury to 7.3 (SD 5.2) at 5 years (p = 0.02). Six patients had a re-rupture (17.6%) and have since undergone a conventional ACL reconstruction for their revision surgery with no issues since then. These patients were found to be younger and have higher initial Marx activity scores than the rest of the cohort (p < 0.05). Conclusion Primary repair with suture tape augmentation for proximal ACL tears demonstrates satisfactory outcomes in 28 patients (82.4%) at 5-year follow-up. Six patients sustained a re-rupture and have no ongoing problems following treatment with a conventional ACL reconstruction. These patients were significantly younger and had higher initial Marx activity scores. Level of evidence Level IV.

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Arthroscopic ACL Reconstruction After Failed ACL Repair

Arthroscopy Techniques ◽

10.1016/j.eats.2020.11.022 ◽

2021 ◽

Vol 10 (4) ◽

pp. e1001-e1005

Author(s):

Thomas Fradin ◽

Ibrahim M. Haidar ◽

Johnny Rayes ◽

Cédric Ngbilo ◽

Thais Dutra Vieira ◽

...

Keyword(s):

Acl Reconstruction ◽

Acl Repair

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Arthroscopic Primary Repair of Proximal Anterior Cruciate Ligament Tears: With or Without Additional Suture Augmentation?

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118s00063 ◽

2018 ◽

Vol 6 (7_suppl4) ◽

pp. 2325967118S0006 ◽

Cited By ~ 2

Author(s):

Anne Jonkergouw ◽

Jelle P. van der List ◽

Gregory S. DiFelice

Keyword(s):

Range Of Motion ◽

Patient Reported Outcomes ◽

Suture Anchor ◽

Primary Repair ◽

Cruciate Ligament ◽

Type I ◽

Acl Repair ◽

Patient Reported ◽

Anterior Cruciate

Objectives: Over the last years, arthroscopic primary repair of anterior cruciate ligament (ACL) tears has shown excellent results owing to appropriate patient selection (only repairing proximal ACL tears and good tissue quality), minimal invasive surgery (arthroscopy) and focus on early range of motion. Some surgeons have repaired proximal ACL tears without suture augmentation while others have used internal suture augmentation to reinforce and thus protect the repaired ligament during range of motion. No studies have yet compared the two surgical techniques. The objective of this study was to compare failure rates, reoperation rates and patient-reported outcomes of arthroscopic primary repair with versus without suture augmentation. Methods: A retrospective search for all patients treated with suture anchor arthroscopic primary ACL repair between April 2008 and June 2016 was performed. All patients with isolated proximal ACL tears (type I) were included. Since the development of internal suture augmentation, this reinforcement was added to the repaired ACLs. Minimum follow-up length was 1.0 years. Results: A total of 56 patients were included (mean age 33 years (range: 14 - 57), 59% male) of which 28 (50%) patients received additional suture augmentation. Mean follow-up was 2.3 years (range: 1.0-9.2). Six of all patients had reruptured their repaired ACL (10.7%), of which four underwent uncomplicated ACL reconstruction and two were treated conservatively. Four reruptures were initially treated with primary repair only (4/28, 14.3%) and two patients with additional suture augmentation (2/28, 7.1%; p = 0.431). During follow-up, three patients underwent reoperation (5.4%; two for medial meniscus tear (one in each group) and one for tibial suture anchor removal of the suture augmentation). Patient-reported outcomes have so far been collected in 20 patients without reruptures (currently collecting), with mean Lysholm score of 96, modified Cincinnati 94, SANE 93, pre-injury Tegner 6.7, postoperative Tegner 6.3 and subjective IKDC 91. Objective IKDC was A in 90%, B in 5%, C in 5%. Conclusion: In this study, the total failure rate of arthroscopic primary ACL repair was 10.7% and was lower with additional suture augmentation (7.1%) than primary repair alone (14.3%). Patients with failed ACL repair underwent uncomplicated primary ACL reconstruction. We recommend adding suture augmentation in high-risk patients (i.e. adolescents, ones with hyperlaxity, high contact sports), to protect the repaired ligament, especially during early range of motion. These data support treating type I proximal ACL tears with arthroscopic primary repair.

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