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.

Augmenting ACL Repair With Suture Tape Improves Knee Laxity: A Biomechanical Study.

Background: Anterior cruciate ligament (ACL) repair is an alternative to reconstruction; however, suture tape support may be necessary to achieve adequate outcomes. Purposes: To investigate the influence of suture tape augmentation (STA) of proximal ACL repair on knee kinematics and to evaluate the effect of the 2 flexion angles of suture tape fixation. Study Design: Controlled laboratory study. Methods: Fourteen cadaveric knees were tested using a 6 degrees of freedom robotic testing system under anterior tibial (AT) load, simulated pivot-shift (PS) load, and internal rotation (IR) and external rotation loads. Kinematics and in situ tissue forces were evaluated. Knee states tested were (1) ACL intact, (2) ACL cut, (3) ACL repair with suture only, (4) ACL repair with STA fixed at 0° of knee flexion, and (5) ACL repair with STA fixed at 20° of knee flexion. Results: ACL repair alone did not restore the intact ACL AT translation at 0°, 15°, 30°, or 60° of flexion. Adding suture tape to the repair significantly decreased AT translation at 0°, 15°, and 30° of knee flexion but not to the level of the intact ACL. With PS and IR loadings, only ACL repair with STA fixed at 20° of flexion was not significantly different from the intact state at all knee flexion angles. ACL suture repair had significantly lower in situ forces than the intact ACL with AT, PS, and IR loadings. With AT, PS, and IR loadings, adding suture tape significantly increased the in situ force in the repaired ACL at all knee flexion angles to become closer to that of the intact ACL state. Conclusion: For complete proximal ACL tears, suture repair alone did not restore normal knee laxity or normal ACL in situ force. However, adding suture tape to augment the repair resulted in knee laxity closer to that of the intact ACL. STA with fixation at 20° of knee flexion was superior to fixation with the knee in full extension. Clinical Relevance: The study findings suggest that ACL repair with STA fixed at 20° could be considered in the treatment of femoral sided ACL tears in the appropriate patient population.

ACL reconstruction provides superior stability than ACL repair in patients with Schenck III and IV knee joint dislocations: first results of a 12 month follow-up study.

PURPOSE: Acute knee dislocation is a rare but devastating multi-ligamentous knee injury with only limited evidence-based surgical technique recommendations. The aim of this study was a comparison of two different anterior cruciate ligament (ACL) restoration techniques as part of an early total surgical care concept: (1) repair of ACL with additional internal bracing (ACLIB) compared to; (2) ACL reconstruction with autograft (ACLR). METHODS: Retrospective, clinical-study of patients with an acute type III or IV knee dislocation (according to Schenck classification), in which the ACL was treated with ACLIB or ACLR within 12 days. The PCL was sutured and internally braced in all cases. Medial and lateral complex injuries were repaired and additionally laterally augmented by an Arciero reconstruction. After a minimum 12 months follow-up different patient-reported outcome measurements (IKDC, Lysholm, VAS, Tegner Score) and instrumental stability assessment by Rolimeter -test and stress radiographs (Telos™) were analyzed. Groups were compared by t test with p < 0.05 considered significant. RESULTS: In total, 20 patients (5 IIIM, 5 IIIL and 10 IV) were included in this study with an average follow-up of 13.7 ± 2.6 months. There were significant differences in instrumental stability testing (side-to-side difference (SSD) of anterior tibial translation: ACLIB 2.7 ± 1.5 mm vs. ACLR 1.3 ± 1.3; p = 0.0339) and stress radiography (SSD ACL: ACLIB 3.4 ± 2.2 mm vs. ACLR 0.4 ± 2.7; p = 0.0249) between groups. ACLIB group showed greater ROM in terms of flexion (SSD Flexion: ACLIB 7.8 ± 9.9° vs. ACLR 16 ± 7.0°; p = 0.0466; Total Flexion overall 125.5 ± 11.8°). No clinically relevant differences in patient-reported outcome scores (Lysholm Score: ACLIB 82 ± 16.4 vs. ACLR 85 ± 10.4; IKDC subjective score: ACLIB 70.4 ± 17 vs. ACLR 76.6 ± 8.3) were determined. CONCLUSION: ACLR provides superior translational stability than ACLIB in terms of instrumental testing and stress radiography. Both techniques were equivalent with respect to PROMS and led to good and excellent clinical results. LEVEL OF EVIDENCE: Retrospective cohort study, III.

Ligament augmentation repair is broadly applied across different orthopaedic subspecialities: an ISAKOS international survey of orthopaedic surgeons.

OBJECTIVES: To evaluate how ligament augmentation repair (LAR) techniques are currently used in different anatomic regions in orthopaedic sports medicine, and to identify the most common indications and limitations of LAR. METHODS: We sent survey invitations to 4,000 members of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine society. The survey consisted of 37 questions total, with members only receiving some branching questions specific to their area of specialisation. Data were analysed using descriptive statistics, and the significance between groups was evaluated using chi-square tests of independence. RESULTS: Of 515 surveys received, 502 were complete and included for the analysis (97% completion rate). 27% of respondents report from Europe, 26% South America, 23% Asia, 15% North America, 5.2% Oceania, and 3.4% Africa. 75% of all survey respondents report using LAR, most frequently using it for the anterior talofibular ligament ( 69%), acromioclavicular joint ( 58%), and the anterior cruciate ligament (51%). Surgeons in Asia report using LAR the most (80%), and surgeons in Africa the least (59%). LAR is most commonly indicated for additional stability (72%), poor tissue quality (54%), and more rapid return-to-play (47%). LAR users state their greatest limitation is cost (62%), while non-LAR users state their greatest reason not to use LAR is that patients do well without it (46%). We also find that the frequency of LAR use among surgeons may differ based on practice characteristics and training. For example, surgeons who treat athletes at the professional or Olympic level are significantly more likely to have a high annual use of LAR (20+ cases) compared to surgeons that treat only recreational athletes (45% and 25%, respectively, p â€‹= â€‹0.005). CONCLUSION: LAR is broadly applied in orthopaedics but its rate of use is not homogeneous. Outcomes and perceived benefits vary depending on factors such as surgeon specialty and treatment population. LEVEL OF EVIDENCE: Level V.

[Augmented primary sutures "internal bracing" following ligamentous elbow dislocation]. / Augmentierte Primärnaht "internal bracing" nach ligamentärer Ellenbogenluxation.

OBJECTIVE: Aim of surgical treatment is the primary stabilization of the unstable elbow following a ligamentous elbow dislocation. INDICATIONS: Ligamentous elbow dislocations are typically accompanied by injuries to the surrounding musculature and collateral ligaments of the elbow joint. Surgical treatment is indicated in case of failure of nonoperative therapy, i.e., when a dislocation can only be prevented in immobilization > 90° and pronation of the elbow or an active muscular centering of the elbow fails after 5-7 days. CONTRAINDICATIONS: Contraindications for a solely "internal bracing" augmented primary suture are generally in the case of accompanying bony injuries in elbow dislocations, extensive soft-tissue injuries, and septic arthritis of the elbow. SURGICAL TECHNIQUE: The augmented primary suture of the elbow is performed using both a lateral (Kocher or Kaplan) and medial (FCU split) approach to the elbow. After reduction of the elbow, the collateral ligaments are first augmented with high-strength polyethylene suture and fixed in the distal humerus together with another high-strength polyethylene augmentation suture. The extensors and flexors are then fixed to the medial and lateral epicondyle, respectively, using suture anchors. POSTOPERATIVE MANAGEMENT: The aim of the postoperative management is early functional exercise of the elbow. The elbow is placed in an elbow brace to avoid varus and valgus load. RESULTS: Between August 2018 and January 2020, a total of 12 patients were treated with an augmented primary suture following unstable ligamentous elbow dislocation. After a mean follow-up of 14 ± 12.7 months, the mean Mayo Elbow Performance Score was 98.5 points with a mean functional arc of 115°. None of the patients reported a recurrent dislocation or persistent instability of the elbow.

Concomitant Patellar Tendon Tear (PTT) with Cruciate and/ Collateral ligament injury (Multi- Ligamentous Knee Injury -MLKI) and new pathoanatomical -Ganga PTT classification aids to strategize treatment options.

INTRODUCTION: Concomitant patellar tendon (PT) tear with cruciate or multi-ligament knee injuries (MLKI) following high-velocity injury requires a systematic approach. METHODS: The study is a retrospective case series of patients (2008-2019) with concomitant PT ligament injury with cruciate or collateral ligament injury (MLKI), including bony avulsion injuries. Isolated cruciate and MLKI without patellar tendon tears are excluded. N = 32 patients (1 female and 31 male) are divided into two groups, Group 1 (11 patients) with PT tear and ACL tear and group 2 (21 patients) with PT tear and MLKIs. Patients were taken up for a single stage in types 1,2,3 and staged repair with reconstruction for types 4,5 of our new classification. All the patients are followed up regularly, and IKDC and Lyshom's score and objective radiological stress x-rays taken at each follow-up RESULTS: Incidence of PTT combined injuries among all knee ligament injuries is 0.57%. The mean age was 35.09+/-11.96 SD(group1) and 36.55+/-11.89 SD(group2). The average follow-up was 34.45 months +/- 12.86SD (group 1) and 35.3 months +/- 15.75 SD (group2). Mean post-operative Lysholm score and IKDC score of group 1 and group 2 improvement was statistically significant p-value <=0.01. The mean post-operative ROM of the two groups were 132.73 (SD 6.46) (Group 1) and 111.75 (15.75) (Group 2) and was a statistically significant p-value <0.01. Residual lag of 30° seen in all patients improved by 3rd month in group 1 and 6th month in group 2. Knee stiffness is seen in 2 patients and superficial infection in 2 patients. CONCLUSION: PTT combined injuries are rare and occurs due to direct impact injuries. Single-stage PT repair with ACL reconstruction gives adequate stability, and extensor lag is eminent and needs supervised rehabilitation. PT with MLKI is a challenging scenario that can be performed in single-stage/multiple stages, depending on the injuries, surgical expertise, and institutional facilities. Newer simplified classification aids surgeons in planning a treatment strategy.

Arthroscopic biological internal bracing with remnant repair for subacute ACL femoral avulsions.

Arthroscopic anterior cruciate ligament (ACL) reconstruction predictably restores sagittal plane knee stability, however its inability to replicate a complex fan-shaped ligament of multiple fascicles, along with deficient restoration of normal rotational knee kinematics, results in failure to reverse a high risk for premature post-traumatic osteoarthritis. Although arthroscopic repair for acute ACL femoral avulsions is proposed to counter these deficiencies, the risk of early failure following non-healing, along with lack of convincing evidence of efficacy has impeded its universal acceptance. Moreover, since ACL repair needs to be performed in the acute phase following injury, it has an increased risk of developing arthrofibrosis, besides precluding any possibility to achieve natural healing of an ACL avulsion with non-operative treatment. The technique of biological internal bracing with remnant repair incorporates the advantages of both reconstruction and repair, and is indicated for patients with persistent ACL deficiency in the subacute phase (6-12 weeks) following an ACL femoral avulsion. This operation essentially involves two steps. The step of biological internal bracing is similar to a conventional ACL reconstruction using a small diameter hamstring graft that is targeted to the centre of the anteromedial ACL bundle on the femur, whereas the tibial socket is located posteriorly within the ACL tibial footprint so as to preserve the anterior fan-shaped morphology of the ACL tibial insertion. The second step involves repairing the remnant ACL tibial stump using one of three techniques. Although technically more complex than an ACL reconstruction, this novel technique provides native anatomy restoration with potential biomechanical and functional advantages, and should be considered for unhealed subacute ACL avulsion injuries.

Rehabilitation and functional outcomes in internally braced and standard ACL reconstructions.

Purpose: The purpose of this study was to compare surgical outcomes in patients who underwent ACL reconstruction, with and without internal bracing, at 1-3, 4-7, and 8-12 months of postoperative physical therapy. Previous studies show that ACL reconstruction with internal bracing allows earlier and more aggressive rehabilitation. Therefore, it was hypothesized that patients with internal bracing would display superior surgical recovery compared to ACL reconstruction alone after adjusting for length of physical therapy.1, 2, 3. Methods: Patients who underwent ACL reconstruction and had a minimum two-year follow-up were included. Demographics including age, gender, use of internal bracing, and pre-operative level of activity were collected. Patient-reported outcomes were assessed using KOOS scores. Results: 46 patients underwent ACL reconstruction between January 2013 and December 2015. The mean age was 31.53 ± 8.37 years. Patients who received ACL reconstruction with internal bracing reported similar improvement in KOOS scores (mean = 42.82 ± 15.44; median = 46.39 [34.52-51.80]) compared to ACL reconstruction alone (mean = 38.18 ± 19.91; median = 40.17 [29.49-53.90]) (p = 0.475). Patients who received ACL reconstruction with internal bracing reported comparable improvement to ACL reconstruction alone at 0-3 months (Internal bracing: mean = 35.39 ± 15.26, median = 40.45 [26.49-47.73]; No internal bracing: mean = 42.51 ± 12.33, median = 39.32 [35.69-52.94], p = 0.4113), 4-7 months (Internal bracing: 41.96 ± 14.49, 45.55 [33.94-52.68]; No internal bracing: 30.64 ± 32.29, 41.65 [26.17-46.12], p = 0.7491) and 8+ months groups (Internal bracing: 63.36 ± 13.06, 63.36 [58.74-67.98]; No internal bracing: 47.05 ± 10.14, 47.05 [43.46-50.63]) (p = 0.6985). Conclusion: This study demonstrates no statistical difference in functional outcome scores when comparing patients with internally braced ACL reconstruction compared to standard reconstruction. Therefore, the increased structural support provided by use of internal bracing in ACL reconstruction does not afford to quicker improvement in patient-reported recovery.

Evidence-Based Surgical Treatment Algorithm for Unstable Syndesmotic Injuries.

BACKGROUND: Surgical treatment of unstable syndesmotic injuries is not trivial, and there are no generally accepted treatment guidelines. The most common controversies regarding surgical treatment are related to screw fixation versus dynamic fixation, the use of reduction clamps, open versus closed reduction, and the role of the posterior malleolus and of the anterior inferior tibiofibular ligament (AITFL). Our aim was to draw important conclusions from the pertinent literature concerning surgical treatment of unstable syndesmotic injuries, to transform these conclusions into surgical principles supported by the literature, and finally to fuse these principles into an evidence-based surgical treatment algorithm. METHODS: PubMed, Embase, Google Scholar, The Cochrane Database of Systematic Reviews, and the reference lists of systematic reviews of relevant studies dealing with the surgical treatment of unstable syndesmotic injuries were searched independently by two reviewers using specific terms and limits. Surgical principles supported by the literature were fused into an evidence-based surgical treatment algorithm. RESULTS: A total of 171 articles were included for further considerations. Among them, 47 articles concerned syndesmotic screw fixation and 41 flexible dynamic fixations of the syndesmosis. Twenty-five studies compared screw fixation with dynamic fixations, and seven out of these comparisons were randomized controlled trials. Nineteen articles addressed the posterior malleolus, 14 the role of the AITFL, and eight the use of reduction clamps. Anatomic reduction is crucial to prevent posttraumatic osteoarthritis. Therefore, flexible dynamic stabilization techniques should be preferred whenever possible. An unstable AITFL should be repaired and augmented, as it represents an important stabilizer of external rotation of the distal fibula. CONCLUSIONS: The current literature provides sufficient arguments for the development of an evidence-based surgical treatment algorithm for unstable syndesmotic injuries.

Anterior cruciate ligament (ACL) repair using cortical or anchor fixation with suture tape augmentation vs ACL reconstruction: A comparative biomechanical analysis.

BACKGROUND: The purpose was to compare knee kinematics in a cadaveric model of anterior cruciate ligament (ACL) repair using an adjustable-loop femoral cortical suspensory (AL-CSF) or independent bundle suture anchor fixation (IB-SAF) with suture tape augmentation to a bone-patellar tendon-bone (BPTB) ACL reconstruction. METHODS: Twenty-seven cadaveric knees were randomly assigned to one of three surgical techniques: (1) ACL repair using the AL-CSF technique with suture tape augmentation, (2) ACL repair using the IB-SAF technique with suture tape augmentation, (3) ACL reconstruction using a BPTB autograft. Each specimen underwent three conditions according to the state of the ACL (native, proximal transection, repair/reconstruction) with each condition tested at four different angles of knee flexion (0°, 30°, 60°, 90°). Anterior tibial translation (ATT) and internal tibial rotation (ITR) were evaluated using 3-dimensional motion tracking software. RESULTS: ACL transection resulted in a significant increase in ATT and ITR when compared to the native state (P < 0.001, respectively). ACL repair with the AL-CSF or IB-SAF technique as well as BPTB reconstruction restored native ATT and ITR at all tested angles of knee flexion, while showing significantly less ATT at 0°, 30°, 60°, and 90° as well as significantly less ITR at 30°, 60°, and 90° of knee flexion when compared to the ACL-deficient state. There were no significant differences in ATT and ITR between the three techniques utilized. CONCLUSION: ACL repair using the AL-CSF or IB-SAF technique with suture tape augmentation as well as BPTB ACL reconstruction each restored native anteroposterior and rotational laxity, without significant differences in knee kinematics between the three techniques utilized. LEVEL OF EVIDENCE: Controlled Laboratory Study.

Graft position at the femoral condyle affects knee mobility after posterior cruciate ligament replacement.

BACKGROUND: In some cases posterior cruciate ligament (PCL) tears require surgical reconstruction. As the femoral footprint of the ligament is quite large, an ideal graft fixation position on the medial notch wall has not yet been identified. The aim of this study was to compare three different graft fixation positions within the anatomical footprint of the PCL and test it for posterior tibial translation at different knee flexion angles. METHODS: In six human knee specimens a drawer test was simulated on a material testing machine by applying load on the tibia. At three different knee flexion angles (0°, 45°, 90°) knee mobility was examined with respect to tibial posterior translation and stiffness for the following conditions: intact ligaments, detached PCL, three different graft fixation positions on the femoral condyle. RESULTS: Replacement of the PCL within its femoral footprint restored knee stability in terms of tibial posterior translation. Low graft position showed comparable drawer displacements to the intact condition for all knee flexion angles (p > 0.344). A higher graft position excessively reduced the posterior translation (p < 0.047) and resulted in a restricted knee mobility and a stiffer joint. CONCLUSIONS: Graft fixation positions on the femoral condyle play a crucial role in post-operative knee mobility and joint functionality after PCL replacement. Even though all graft fixation positions were placed within the femoral footprint of a native PCL, only the lower position on the medial notch wall showed comparable posterior tibial translation to an intact PCL.

Rehabilitation Principles to Consider for Anterior Cruciate Ligament Repair.

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.

[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.

Temporary Internal Bracing for Pediatric Odontoid Synchondrosis Fracture.

Children are predisposed to injuries of the upper cervical spine given their relatively immature osteology, ligamentous laxity, underdeveloped musculature, and larger ratios of head to body mass. Odontoid process fractures involving the synchondroses are among the most common of these injuries. Though many of these fractures can be treated conservatively with external bracing, fractures with significant displacement that are unable to be reduced require operative management. In these cases, most patients undergo C1-2 posterior fusion with arthrodesis with permanent limitation to atlantoaxial range of motion (ROM). Here, we present a novel operative approach to manage odontoid synchondrosis fractures with temporary internal bracing via C1-2 posterior instrumentation without arthrodesis. We saw a three-year-old female who presented after a motor vehicle collision with a displaced odontoid synchondrosis fracture that was unable to be adequately reduced in a closed fashion. In an attempt to preserve maximal atlantoaxial ROM, temporary internal bracing was carried out with excellent results.

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.

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.

Self-Tensioning Feature of Knotless Suture Anchor Provides Reproducible Knotless Fixation Independent of Initial Tension.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction with suture tape reinforcement has been shown to biomechanically reduce elongation and increase ultimate strength. However, the amount and consistency of the achieved tension after primary fixation using knotless suture anchors remains unclear. PURPOSE: To determine whether initial tensioning of suture tape before fixation with a knotless suture anchor significantly affects final tension of the suture tape. STUDY DESIGN: Controlled laboratory study. METHODS: We secured 15 pairs of Sawbones blocks with predrilled tunnels to a tensile testing machine. Suture tape was inserted through a suspensory fixation button on the representative femoral block and threaded top-down through the base of the tibial block over an attachable button system. The suture tape was attached with a knotless suture anchor in a predrilled and tapped hole on the tibial block under the following pretensioning conditions: (1) slight tension of 5 N, (2) no tension, and (3) initial slack. The suture anchor was inserted as the load-time data were recorded. After initial block testing, a porcine model of 24 tibias was used to test the same pretensioning conditions. The initial loads during anchor insertion and screw-in were measured, as well as final tension. RESULTS: During block testing, no difference in final tensioning was found when comparing the slight-tension, no-tension, and slack groups (42.3 ± 5.3, 37.7 ± 6.4, and 40.2 ± 7.0 N, respectively; P = .528). Similar to block testing, no difference in final tensioning was found when comparing the slight-tension, no-tension, and slack groups using the porcine model (43.64 ± 6.69, 48.09 ± 13.93, and 44.52 ± 6.84 N, respectively; P = .633). CONCLUSION: The final tension of the suture tape construct appears to be reproducible and consistent, independent of the initial tension introduced with suture anchor placement within the tested parameters. CLINICAL RELEVANCE: The results of the current study can help optimize the placement technique of independent suture tape reinforcement for ACL reconstruction, which is a promising strategy to help prevent ACL rerupture, particularly in the early phases of postoperative rehabilitation.

[Combined PCL ligament bracing and ACL reconstruction in acute knee dislocation (Schenck IV) - The Hamburg Approach : Video article]. / Hamburger Konzept der operativen Versorgungsstrategie einer akuten Kniegelenkluxation (Schenck IV) : Videobeitrag.

OBJECTIVE: Stepwise reconstruction of knee stability and physiological kinematics in acute knee dislocation. INDICATIONS: The operative technique is demonstrated in a case of multiligamentous injury of the knee with involvement of both cruciate ligaments and additional medial and lateral peripheral injuries (type IV according to Schenck classification). CONTRAINDICATIONS: Critical soft tissue conditions, infections, old age, obesity, lack of compliance. SURGICAL TECHNIQUE: Time-limited arthroscopy in order to primarily identify and treat posterior horn/root injuries of the meniscus and concomitant intra-articular injuries. Anatomical placement of anterior cruciate ligament (ACL) drill wires for later ACL tunnel drilling is arthroscopically guided. Subsequent conversion to an anteromedial arthrotomy and ligament bracing of the posterior cruciate ligament. The ACL is reconstructed using the ipsilateral semitendinosus tendon. Medial and lateral peripheral injures are anatomically reconstructed followed by a posterolateral augmentation in a technique described by Arciero. FOLLOW-UP: Limited weight bearing for 6 weeks and stepwise increase of flexion using a standard knee brace and close clinical monitoring. EVIDENCE: Ligament bracing of both cruciate ligaments is an established treatment technique in acute knee dislocations and has been proven to achieve good to excellent clinical results. In an ongoing clinical study primary ACL reconstruction as a modified treatment approach indicated superior stability in a 12-month follow-up in patients with acute knee dislocations.

Clinical assessment and comparison of ACL reconstruction using synthetic graft (Neoligaments versus FiberTape).

BACKGROUND: Due to the low potential for primary biological healing of the anterior cruciate ligament (ACL), the most popular approach is currently reconstruction using a graft. Recent research indicates that the technique of strengthening a damaged ligament with synthetic tapes (internal bracing) may be an alternative to reconstructive treatment, especially in cases of partial ACL damage. OBJECTIVES: To compare and evaluate the possibility of using a synthetic graft (Neoligaments or FiberTape) to treat partial lesions of the ACL. MATERIAL AND METHODS: This was a retrospective cohort study. Selected from a pool of 128 patients undergoing primary unilateral intra-articular ACL reconstruction due to partial lesion of the ACL, group I (Neoligaments) and group II (FiberTape) each included 30 patients. Range of motion (ROM), the Lachman test, the anterior drawer test and the pivot-shift test, the Lysholm Knee Scoring Scale, and International Knee Documentation Committee (IKDC) 2000 scale were used for assessment. Follow-up was carried out after 2 years. RESULTS: The knee joint regained anterior stability in both the subjective and objective assessments in all patients in both groups. The subjective results were respectively: in group I, 97.2 ±3.2 points on the Lysholm scale and 93.9 ±6.1 points on the IKDC 2000 scale; in group II, 96.1 ±4.9 points on the Lysholm scale and 93.2 ±6.8 points on the IKDC 2000 scale. Group comparison of the results of the IKDC 2000 scale, Lysholm Scale and ROM obtained postoperatively showed no statistically significant differences between groups. CONCLUSIONS: Reconstruction of partial ACL lesions using a synthetic graft allows regained stability of the knee joint. The results of subjective assessment are comparable with the functional assessment results. The comparison between Neoligaments and FiberTape shows the same functional and objective results, although FiberTape is preferable from an economical perspective.

Comparison of Three Different Internal Brace Augmentation Techniques for Scapholunate Dissociation: A Cadaveric Biomechanical Study.

Internal bracing (IB) is an augmentation method using high-strength nonabsorbable tape. However, there is no detailed information about the direction, location, or number of IBs required for scapholunate interosseous ligament (SLIL) injury repair. Thus, this study compared the biomechanical characteristics of short-transverse IB, long-oblique IB, and the combination of short-transverse and long-oblique (Combo) IB for SLIL injury in a biomechanical cadaveric model. We prepared nine fresh-frozen full upper extremity cadaveric specimens for this study. The scapholunate distance, scapholunate angle, and radioscaphoid angle were measured using the MicroScribe digitizing system with the SLIL intact, after scapholunate dissociation and the three different reconstructions. Three-dimensional digital records were obtained in six wrist positions in each experimental condition. Short-transverse IB had a similar effect compared with long-oblique IB in addressing the widening of the scapholunate distance. However, both were less effective than Combo IB. For scaphoid flexion deformity, short-transverse IB had minimal effect, while long-oblique IB had a similar effect compared to Combo IB. Combo IB was the most effective for improving distraction intensity and rotational strength. This study provides important information about the biomechanical characteristics of three different IB methods for SLIL injury and may be useful to clinicians in treating scapholunate dissociation.