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

2020 ◽  
Vol 8 (1) ◽  
pp. 232596711989742 ◽  
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.

Rehabilitation Principles to Consider for Anterior Cruciate Ligament Repair

2021 ◽  
pp. 194173812110329
Author(s):  
Jocelyn Wu ◽  
Jamie L. Kator ◽  
Michael Zarro ◽  
Natalie L. Leong
Keyword(s):  
Anterior Cruciate Ligament ◽  
Cruciate Ligament ◽  
Ligament Repair ◽  
Acl Repair ◽  
Pubmed Database ◽  
Anterior Cruciate Ligament Repair ◽  
Ligament Augmentation ◽  
Internal Bracing ◽  
Anterior Cruciate ◽  
Repair Techniques

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.

scholarly journals Treatment of Acute Proximal Anterior Cruciate Ligament Tears—Part 1: Gap Formation and Stabilization Potential of Repair Techniques

2020 ◽  
Vol 8 (1) ◽  
pp. 232596711989742
Author(s):  
Samuel Bachmaier ◽  
Gregory S. DiFelice ◽  
Bertrand Sonnery-Cottet ◽  
Wiemi A. Douoguih ◽  
Patrick A. Smith ◽  
...  
Keyword(s):  
Cruciate Ligament ◽  
Gap Formation ◽  
Knot Tying ◽  
Acl Repair ◽  
Time Zero ◽  
Cortical Button ◽  
Fixation Techniques ◽  
Anterior Cruciate ◽  
Anchor Fixation ◽  
Repair Techniques

Background: Recently, there has been a resurgence of interest in primary repair of the anterior cruciate ligament (ACL), with fixation techniques evolving. However, to date, there have been no biomechanical studies comparing fixed to adjustable fixation repair techniques. Hypothesis: Adjustable ACL repair provides for improved stabilization compared with fixed techniques with respect to both gap formation and residual load-bearing capability. Study Design: Controlled laboratory study. Methods: A total of 4 different ACL repair techniques (n = 5 per group), including single– and double–cinch loop (CL) cortical button fixation as well as knotless single–suture anchor fixation, were tested using a porcine model. For adjustable single-CL loop fixation, additional preconditioning (10 cycles at 0.5 Hz) was performed. The force after fixation and the actuator displacement to achieve a time-zero preload of 10 N were measured for fixed techniques. Incrementally increasing cycling (1 mm/500 cycles) from 1 to 8 mm was performed for 4000 cycles at 0.75 Hz before pull to failure (50 mm/min). The final residual peak load and gap formation for each test block were analyzed as well as ultimate strength. Results: Knot tying of a single-CL over a button (mean ± SD, 0.66 ± 0.23 mm) and knotless anchor fixation (0.20 ± 0.12 mm) resulted in significant time-zero gaps ( P < .001) and significantly higher overall gap formation at reduced residual loading (analysis of covariance, P < .001) compared with both the double-CL loop and adjustable fixation techniques. The adjustable group showed the highest failure load and stiffness, at 305.7 N and 117.1 N/mm, respectively. The failure load of the knotted single-CL group was significantly reduced compared with all other groups ( P < .001). Conclusion: Adjustable single-CL cortical button fixation with intraoperative preconditioning optimized time-zero ACL tension and led to significantly improved stabilization and reduced gap formation, with the highest ultimate strength. Single-CL loop knot tying over the button and knotless anchor fixation resulted in time-zero gaps to achieve slight tension on the ACL and significantly higher gap formation at reduced load-bearing capability. Clinical Relevance: Although the clinical relevance of gap formation is uncertain, a biomechanical understanding of the stabilization potential of current ACL repair techniques is pertinent to the continued evolution of surgical approaches to enable better clinical outcomes.

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

2017 ◽  
Vol 46 (9) ◽  
pp. 2291-2298 ◽  
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.

scholarly journals Anterior cruciate ligament – to repair or not to repair?

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.

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

2020 ◽  
Vol 8 (12) ◽  
pp. 232596712096855
Author(s):  
Graeme P. Hopper ◽  
Joanna M.S. Aithie ◽  
Joanne M. Jenkins ◽  
William T. Wilson ◽  
Gordon M. Mackay
Keyword(s):  
Anterior Cruciate Ligament ◽  
Cruciate Ligament ◽  
Anterolateral Ligament ◽  
Rotational Stability ◽  
Acl Repair ◽  
Patient Reported ◽  
Internal Brace ◽  
The Mean ◽  
Anterior Cruciate

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.

scholarly journals Biologic Approaches for the Treatment of Partial Tears of the Anterior Cruciate Ligament

2017 ◽  
Vol 5 (1) ◽  
pp. 232596711668172 ◽  
Author(s):  
Ignacio Dallo ◽  
Jorge Chahla ◽  
Justin J. Mitchell ◽  
Cecilia Pascual-Garrido ◽  
John A. Feagin ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Growth Factors ◽  
Platelet Rich Plasma ◽  
Cruciate Ligament ◽  
Return To Sport ◽  
Acl Repair ◽  
Biologic Treatment ◽  
Partial Tears ◽  
Anterior Cruciate ◽  
Repair Techniques

Background: Anterior cruciate ligament reconstruction (ACLR) has been established as the gold standard for treatment of complete ruptures of the anterior cruciate ligament (ACL) in active, symptomatic individuals. In contrast, treatment of partial tears of the ACL remains controversial. Biologically augmented ACL-repair techniques are expanding in an attempt to regenerate and improve healing and outcomes of both the native ACL and the reconstructed graft tissue. Purpose: To review the biologic treatment options for partial tears of the ACL. Study Design: Review. Methods: A literature review was performed that included searches of PubMed, Medline, and Cochrane databases using the following keywords: partial tear of the ACL, ACL repair, bone marrow concentrate, growth factors/healing enhancement, platelet-rich plasma (PRP), stem cell therapy. Results: The use of novel biologic ACL repair techniques, including growth factors, PRP, stem cells, and bioscaffolds, have been reported to result in promising preclinical and short-term clinical outcomes. Conclusion: The potential benefits of these biological augmentation approaches for partial ACL tears are improved healing, better proprioception, and a faster return to sport and activities of daily living when compared with standard reconstruction procedures. However, long-term studies with larger cohorts of patients and with technique validation are necessary to assess the real effect of these approaches.

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

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.

scholarly journals Primary ACL Repair vs Reconstruction: Investigating the Current Conventional Wisdom

2018 ◽  
Vol 6 (6_suppl3) ◽  
pp. 2325967118S0004 ◽  
Author(s):  
Gabriella Bucci ◽  
Michael Begg ◽  
Kevin Pillifant ◽  
Steven B. Singleton
Keyword(s):  
Anterior Cruciate Ligament ◽  
Sports Medicine ◽  
Cruciate Ligament ◽  
Conventional Wisdom ◽  
Acl Repair ◽  
Arthroscopic Technique ◽  
Anterior Cruciate ◽  
Injured Knee

BACKGROUND: “Why try to convert other collagen substitutes into ligament if the original can be preserved?” said Sherman1. Nowadays, reconstruction became the gold standard treatment for ACL injuries. Despite current treatment, secondary knee osteoarthritis has been described in more than 70% of the injured patients after 10 years follow up.2 Recent studies have reported that tears involving the proximal ACL have an intrinsic healing response. This response has been compared to the one observed in MCL injuries.3, 4. OBJECTIVE: The aim of this study is to initiate a scientific analysis of our experience in patients diagnosed with an acute, proximal ACL tear treated with a primary repair arthroscopic technique. We suggest the creation of a symposium that reconsiders the ACL repair as a tool for treatment, on a selected subset of patients. METHODS: We analyzed retrospectively the data of 12 consecutive patients diagnosed clinically and radiologically (MRI) with proximal ACL tears in our clinic. The inclusion criteria were: proximal ACL tear (type 1 tear in Sherman´s classification), good remaining ACL quality tissue and less than 3 months from injury. The mean age at time of surgery was 33 years (16 to 55). Patients included in this study are athletes either at an amateur or professional level. The technique consists of an anatomical reinsertion of native ACL by reinforcing the anteromedial and posterolateral bundles of the ACL with a series of high strength locking Bunnell-type sutures, moving up the ligament from distal to proximal with an arthroscopic suture passer. The normal ACL insertional footprint within the notch is then debrided to provide a bleeding surface for healing. Finally, the torn ligament is opposed to the native footprint using 1-2 absorbable anchors that recreate the anatomic bundle insertional sites of the native ACL. RESULTS: Associated injuries were found in 7 of the 12 patients, these included 4 knees with lateral and 1 with medial meniscal tear which were repaired in the same procedure. Also, one knee had a medial bucket handle tear, partial meniscectomy was performed, and one knee with a combined ACL/MCL injury in which the MCL was simultaneously repaired. In our ongoing series, were excluded patients that had sustained complex knee injuries with multi-ligament damage (except ACL/MCL injuries), those with ACL re-ruptures, and previous knee surgery with cartilage repair procedures. Validated functional outcomes scores were collected after a mean follow up of 20 months (14-26). For the IKDC subjective score 11 of 12 patients rated their knees as normal or nearly normal. Lachman and Pivot Shift was negative in all patients. Lysholm score postoperatively averaged 93.5 ± 7; preoperatively 48 ± 7. Tegner preinjury 7.5 ± 1.2 postinjury: 7 ± 1.4. The KT-1000 knee arthrometer, objectively measured < 3 mm of anterior tibial motion relative to the femur in the injured knee compared to the non-injured knee at all levels of force, including manual max tests, in all patients included in the study. No complications or further surgeries are reported up to date. CONCLUSION: The keys to success include: Proper patient selection, early intervention, all arthroscopic technique, appropriate suture control of the torn ACL fibers, and stable opposition to a bleeding bone surface at the native attachment site within the femoral notch. Long-term data is pending. However, basic science and early clinical studies are promising. REFERENCES Mark F. Sherman, MD, Lawernce Lieber, MD, Joel R. Bonamo, MD, Luga Podesta, MD, Ira Reiter, RPT., The long-term followup of primary anterior cruciate ligament repair, 1991, The American Journal of Sports Medicine, Vol. 19, No 3. Martha M. Murray, MD. Current Status and Potential for Primary ACL Repair. 2009. Clin Ssports Med. Duy Tan Nguyen, Tamara H. Ramwadhdoebe, Cor P. van der Hart, Leendert Blankervoort, Paul Peter Tak, Cornelis Niek van Dijk., Intrinsic Healing Response of the Human Anterior Cruciate Ligament: An Histological Study of Reattached ACL Remnants, 2014, Journal of Orthopaedic Research. Martha M. Murray, MD, Braden C. Fleming, Ph.D., Use of a Bioactive Scaffold to Stimulate ACL Healing Also Minimizes Post-traumatic Osteoarthritis after Surgery, 2014, American Journal of Sports Medicine. Primary ACL Repair vs Reconstruction: Investigating the Current Conventional Wisdom

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