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

PURPOSE: The aim of this study is to investigate clinical and magnetic resonance imaging (MRI) outcomes after anterior cruciate ligament (ACL) repair using the suture tape augmentation (STA) technique. METHODS: This prospective interventional case series included 35 patients who underwent STA ACL repair and were all followed up for 2 years. The ACL rupture was between 4 and 12 weeks old and per-operatively confirmed repairable. The International Knee Documentation Committee (IKDC), and Lysholm and Tegner scores were collected together with return to work (RTW), return to sport (RTS), re-rupture, and re-intervention rate. Lachman testing was performed and ACL healing was evaluated on MRI using a grading scale based on the ACL's morphology and signal intensity with grade 1 representing good ACL healing and grade 3 representing poor ACL healing. RESULTS: The number of patients who returned to their pre-rupture level for IKDC, Lysholm, and Tegner scores at 2 years of follow-up are 17/26 (65.4%), 13/25 (52.0%), and 18/27 (66.7%) patients, respectively. Median RTW and RTS periods were 5.5 weeks (range 0-32 weeks) and 6 months (range 2-22 months), respectively. The Lachman side-to-side difference decreased significantly (P < 0.001) to less than 3 mm after surgery and remained stable. Four patients [11.4%, 95% CI (3.2, 26.7)] suffered from a re-rupture and three other patients [8.6%, 95% CI (1.8, 23.1)] needed a re-intervention for another reason than re-rupture. MRI follow-up of 31 patients showed overall grade 1 ACL healing in 14 (45.2%) patients, grade 2 ACL healing in 11 (35.5%) patients, and grade 3 ACL healing in 6 (19.4%) patients. A higher risk of re-rupture was associated with grade 3 ACL healing at 6 months post-operatively and a pre-operative Tegner score of ≥ 7. CONCLUSION: This study shows that treatment of the acute, repairable ACL with the STA technique leads to a stable knee and favorable patient-reported outcome measures (PROMs). However, the re-rupture rate of 11.4% within the 2-year follow-up is a concern. LEVEL OF EVIDENCE: IV.

Femoral anteversion measurement : evaluation of inter- and intraobserver reliability.

The aim of this study was to evaluate the inter- and intraobserver reliability of a CT-based femoral anteversion measurement. 17 CT scans showing an abnormal anteversion on one side were presented to 6. Three measurements of all scans were obtained : two bilateral measurements and a third measurement with a flipped CT scan. Interobserver correlation results using the spearman test for left, right and anteversion difference had a mean of respectively : 0.918, 0.760 and 0.757. Intraobserver correlation had a maximum of respectively : 0,99, 0,89 and 0,94. Correlation coefficients were consistently higher for the second measurement. The lower correlation boarder of 0,8 was often exceeded. Intraobserver correlation was higher than interobserver correlation. As we evaluated a high variance in interobserver reliability, we recommend an accurate and objective measurement of the anteversion angle. A personal measurement and comparison to the radiological protocol is necessary.

Tips and Tricks to Optimize Surgical Outcomes After ACL Repair Using Dynamic Intraligamentary Stabilization.

PURPOSE: This paper describes technical difficulties and outcomes for the first 15 patients treated with Dynamic Intraligamentary Stabilization (DIS) for anterior cruciate ligament (ACL) repair. METHODS: The first 15 patients treated with DIS were included. To optimize the inclusion process, a new pre-operative pathway was developed. All intra-operative technical problems were recorded. During the 2-year follow-up period, patient-related outcome measures, return to work, anterior-posterior knee laxity using a Rolimeter and ACL healing as revealed by MRI follow-up scans were recorded. RESULTS: During 11 DIS procedures, 15 technical problems were encountered. Six were surgeon-related and 9 were material-related. All problems were resolved intra-operatively. Repeat surgery was performed in 4 patients due to arthrofibrosis and in 1 due to a cyclops lesion. The DIS implant was removed in all 5 patients. According to the Tegner score, 7 of 10 (70%) patients returned to the pre-injury level of sporting activity within 6 months. The mean return to work time was 5.4 (SD 3.6) weeks. On MRI, 10 patients showed normal ACL healing (Grade 1) and 3 showed a high repair signal intensity (Grade 2). Although 2 patients showed no signs of ACL healing on MRI (Grade 3), no instability was reported or measured post-operatively or after the DIS implant was removed. CONCLUSION: All intra-operative technical problems were resolved and did not lead to conversion to ACL reconstruction. We share tips and tricks that could assist surgeons who are just starting to use the DIS technique.

Study protocol: a single-blind, multi-center, randomized controlled trial comparing dynamic intraligamentary stabilization, internal brace ligament augmentation and reconstruction in individuals with an acute anterior cruciate ligament rupture: LIBRƎ study.

BACKGROUND: The current gold standard for the treatment of an anterior cruciate ligament (ACL) rupture is reconstruction with tendon graft. Recently, two surgical ACL repair techniques have been developed for treating an acute ACL rupture: Dynamic Intraligamentary Stabilization (DIS, Ligamys®) and Internal Brace Ligament Augmentation (IBLA, InternalBrace™). We will conduct a single-blind, multi-center, randomized controlled trial which compares DIS, IBLA and reconstruction for relative clinical efficacy and economic benefit. METHODS: Subjects, aged 18-50 years, with a proximal, primary and repairable ACL rupture will be included. DIS is preferably performed within 4 weeks post-rupture, IBLA within 12 weeks and reconstruction after 4 weeks post-rupture. Patients are included in study 1 if they present within 0-4 weeks post-rupture and surgery is feasible within 4 weeks post-rupture. Patients of study 1 will be randomized to either DIS or IBLA. Patients are included in study 2 if they present after 4 weeks post-rupture and surgery is feasible between 5 and 12 weeks post-rupture. Patients of study 2 will be randomized to either IBLA or reconstruction. A total of 96 patients will be included, with 48 patients per study and 24 patients per study arm. Patients will be followed-up for 2 years. The primary outcome is change from baseline (pre-rupture) in International Knee Documentation Committee score to 6 months post-operatively. The main secondary outcomes are the EQ-5D-5 L, Tegner score, Lysholm score, Lachman test, isokinetic and proprioceptive measurements, magnetic resonance imaging outcome, return to work and sports, and re-rupture/failure rates. The statistical analysis will be based on the intention-to-treat principle. The economic impact of the surgery techniques will be evaluated by the cost-utility analysis. The LIBRƎ study is to be conducted between 2018 and 2022. DISCUSSION: This LIBRƎ study protocol is the first study to compare DIS, IBLA and ACL reconstruction for relative clinical efficacy and economic benefit. The outcomes of this study will provide data which could aid orthopaedic surgeons to choose between the different treatment options for the surgical treatment of an acute ACL rupture. TRIAL REGISTRATION: This study is registered at ClinicalTrials.gov; NCT03441295. Date registered 13.02.2018.

Medial Patellofemoral Ligament Repair With Suture Tape Augmentation.

The medial patellofemoral ligament (MPFL) is the main restraining force in the first 20° of flexion against lateral patellar displacement and is disrupted after patellar subluxation or dislocation. MPFL reconstruction is frequently performed when conservative management fails and the patient has recurrent patellar dislocations. However, a variety of complications have been reported in the literature with this procedure. Internal bracing with suture tape augmentation encourages healing and allows early mobilization. This article describes, with video illustration, MPFL repair with suture tape augmentation.

Posterior Cruciate Ligament Repair With Suture Tape Augmentation.

The posterior cruciate ligament (PCL) acts as the primary restraint to posterior tibial translation of the knee. Injuries to the PCL are rare in isolation and more often are associated with multiligament injuries to the knee. Several PCL reconstruction and PCL repair techniques have been described in the literature, but no single technique has been shown to be the most superior. Internal bracing with suture tape augmentation encourages natural healing and allows early mobilization. This article describes, with video illustration, PCL repair with suture tape augmentation.

Primary Posterior Cruciate Ligament Repair With The Novel Suture Tape Augmentation Technique.

BACKGROUND: A posterior cruciate ligament (PCL) rupture is less common than an anterior cruciate ligament (ACL) rupture. PCL reconstruction remains controversial with variable outcomes and problems. The encouraging results of the novel ACL repair techniques led to renewed interest in PCL repair. Primary arthroscopic PCL repair has been rarely discussed and literature is scarce. To the best of our knowledge, no PCL repair patient outcome has been reported with one of the novel PCL repair techniques. We present the first case report of two patients who have been treated with the novel PCL repair technique, the suture tape augmentation technique. CASE DESCRIPTION: Two patients who underwent primary PCL repair after an acute PCL rupture with a two-year follow up are presented. Patients were evaluated according to the Lysholm scale, the International Knee Documentation Committee (IKDC), and the Tegner activity scale. Follow up also included objective physical examinations-knee function and posterior drawer test using a rolimeter-and magnetic resonance imaging (MRI). Physical examinations were performed at three months, six months, one year, and two years after surgery. OUTCOMES: At two-year follow up, both patients had a full range of motion and experienced no pain, nor swelling. IKDC scores were 83% (good) and 100% (excellent), Lysholm scores were 99 and 100 two years after surgery. At three months postoperative, the Tegner activity scale equaled the preinjury Tegner activity scale. One patient was horseback riding within three months. There were some increased posterior translation differences after two years-+2 and +3mm-compared with six weeks postoperative. MRI showed a healed PCL in both cases. DISCUSSION: PCL repair could be a promising treatment option for acute PCL ruptures. Advantages of this technique are the retaining of the natural proprioceptive capacities due to preserving native PCL fibers, the surgical technique is less invasive compared to a reconstruction, and no donor graft morbidity is expected as no graft is needed. CONCLUSION: In these two cases, good subjective and objective results are demonstrated after PCL repair using the novel suture tape augmentation technique. MRI confirmed the healing of the PCL. Although this is a small case series, as PCL ruptures are less common compared to ACL ruptures, it is a stepping-stone for further PCL repair research.

Anterior cruciate ligament repair with Independent Suture Tape Reinforcement: a case series with 2-year follow-up.

PURPOSE: The treatment of acute anterior cruciate ligament (ACL) ruptures with a repair technique has recently regained interest. A novel ACL repair technique was described using Independent Suture Tape Reinforcement with 2-year follow-up results. METHODS: Forty-two consecutive patients with an acute ACL rupture undergoing repair using this technique were followed up for a minimum of 2 years. Patients with mid-substance, distal ACL ruptures, poor ACL tissue quality or retracted ACL remnants as well as patients with multi-ligament injuries were excluded. Knee Injury and Osteoarthritis Outcome Score (KOOS), Visual Analogue Pain Scale (VAS-pain), Veterans RAND 12 Item Health Survey (VR-12) and the Marx Activity scale were collected by online questionnaires. Two-year postoperative patients were asked by telephone if they had experienced a rerupture. RESULTS: All the KOOS subscales improved significantly in comparison to the preoperative score. The largest improvement of all scores was seen at 3 months postoperatively which is significant in all cases. The KOOS sport and recreation showed a meaningful change and the largest improvement of the KOOS subscales at 3 months postoperatively, as well as the highest total improvement at 1 year postoperatively compared to preoperatively. The VAS-pain and VR-12 physical score improved significantly, however the Marx activity scale decreased significantly in comparison to preoperative scores. Two patients reported a rerupture (4.8%, CI 1.7-11.2%). CONCLUSIONS: This is the first case series that described the 2-year follow-up results of patients with an acute, proximal ACL rupture, treated with the Independent Suture Tape Reinforcement repair technique. A meaningful KOOS sport and recreation change and significant improvements in the KOOS, VAS-pain and VR-12 physical scores as well as a significant decrease of the Marx activity scale in comparison to preoperative scores are demonstrated. Two of the 42 patients (4.8%) reported an ACL rerupture. Repair with this technique could be clinically relevant as a treatment option for patients with an acute, proximal ACL rupture which is not retracted and of good tissue quality. LEVEL OF EVIDENCE: IV.

Posterolateral Corner Repair With Suture Tape Augmentation.

The posterolateral corner (PLC) of the knee is the main restraint to varus forces of the knee as well as posterolateral rotation of the tibia relative to the femur. Primary PLC repairs have been associated with a high failure rate in past literature. However, with modern improved arthroscopic instrumentation and devices, there has been a renewed interest in repair of the ligaments around the knee. Internal bracing with suture tape augmentation encourages healing and allows early mobilization. This article describes, with video illustration, PLC repair with suture tape augmentation.

Anterolateral Ligament Repair With Suture Tape Augmentation.

Recent insights into the structure and function of the anterolateral ligament (ALL) of the knee has resulted in a recognition of its contribution in rotational control of the knee. Several ALL reconstruction techniques have been described in the literature. This article describes, with video illustration, a percutaneous repair technique using suture tape augmentation. A tendon graft is not needed. This technique allows early mobilization and encourages natural healing of the ligament by protecting the ligament during the healing phase as a secondary stabilizer.

Anterior Cruciate Ligament Repair Using Independent Suture Tape Reinforcement.

Recently there has been renewed interest in primary repair of the anterior cruciate ligament (ACL). Repair of the acute proximal ruptured ACL can be achieved with the independent suture tape reinforcement ACL repair technique. The independent suture tape reinforcement technique reinforces the ligament as a secondary stabilizer, encouraging natural healing of the ligament by protecting it during the healing phase and supporting early mobilization. The purpose of this article is to describe, with video illustration, this ACL repair technique.

Comparison of 1.5- and 3-T MR imaging for evaluating the articular cartilage of the knee.

PURPOSE: The aim of this prospective study was to compare routine MRI scans of the knee at 1.5 and 3 T obtained in the same individuals in terms of their performance in the diagnosis of cartilage lesions. METHODS: One hundred patients underwent MRI of the knee at 1.5 and 3 T and subsequent knee arthroscopy. All MR examinations consisted of multiplanar 2D turbo spin-echo sequences. Three radiologists independently graded all articular surfaces of the knee joint seen at MRI. With arthroscopy as the reference standard, the sensitivity, specificity, and accuracy of 1.5- and 3-T MRI for detecting cartilage lesions and the proportion of correctly graded cartilage lesions within the knee joint were determined and compared using resampling statistics. RESULTS: For all readers and surfaces combined, the respective sensitivity, specificity, and accuracy for detecting all grades of cartilage lesions in the knee joint using MRI were 60, 96, and 87% at 1.5 T and 69, 96, and 90% at 3 T. There was a statistically significant improvement in sensitivity (p < 0.05), but not specificity or accuracy (n.s.) for the detection of cartilage lesions at 3 T. There was also a statistically significant (p < 0.05) improvement in the proportion of correctly graded cartilage lesions at 3 T as compared to 1.5 T. CONCLUSION: A 3-T MR protocol significantly improves diagnostic performance for the purpose of detecting cartilage lesions within the knee joint, when compared with a similar protocol performed at 1.5 T. LEVEL OF EVIDENCE: III.

Prospective comparison of 1.5 and 3.0-T MRI for evaluating the knee menisci and ACL.

BACKGROUND: MRI (magnetic resonance imaging) is widely used to diagnose meniscal pathology and ACL (anterior cruciate ligament) tears. Because of the enhanced signal-to-noise ratio and improved image quality at higher field strength, knee MRI equipment is shifting from 1.5 to 3.0 T. To date, objective evidence of improved diagnostic ability at 3.0 T is lacking. The purpose of this prospective study was to assess the accuracy of 1.5 and 3.0-T MRI of the knee, in the same individuals, for diagnosing meniscal pathology and ACL tears, utilizing arthroscopy as the reference standard. METHODS: Two hundred patients underwent MRI of the knee at 1.5 and 3.0 T. All MRI examinations consisted of multiplanar turbo spin-echo sequences. One hundred patients underwent subsequent knee arthroscopy. Two blinded independent radiologists assessed all MRI studies to identify meniscal pathology and ACL tears. In patients with MRI results indicating the need for surgical treatment, the sensitivity and specificity of the 1.5 and 3.0-T protocols for detecting these lesions were determined, utilizing arthroscopy as the reference standard, and compared with use of the McNemar test. The kappa statistic for inter-reader agreement in the 200 patients was calculated. RESULTS: For medial meniscal tears, the mean sensitivity and specificity for the two readers were 93% and 90%, respectively, at 1.5 T and 96% and 88%, respectively, at 3.0 T. For lateral meniscal tears, the mean sensitivity and specificity were 77% and 99%, respectively, at 1.5 T and 82% and 98%, respectively, at 3.0 T. For ACL tears, the mean sensitivity and specificity were 78% and 100%, respectively, at 1.5 T and 80% and 100%, respectively, at 3.0 T. None of the values for either reader differed significantly between the 1.5 and 3.0-T MRI protocols. Inter-reader agreement was almost perfect to perfect (kappa = 0.82 to 1.00). CONCLUSIONS: Routine use of a 3.0-T MRI protocol did not significantly improve accuracy for evaluating the knee menisci and ACL compared with a similar 1.5-T protocol.

Diagnostic performance of 3D SPACE for comprehensive knee joint assessment at 3 T.

OBJECTIVE: To assess the diagnostic performance of 3D sampling perfection with application-optimised contrasts using variable flip-angle evolution (SPACE) turbo spin-echo (TSE) sequences compared to 2D TSE for comprehensive knee assessment at 3 T. METHODS: From January to July 2011, isotropic 3D SPACE was added to a 2D knee protocol at 3 T. Forty patients underwent subsequent arthroscopy. Three readers independently assessed MR images for meniscus, anterior cruciate ligament (ACL) and cartilage lesions. Readers 1 and 2 evaluated 3D and 2D data at separate sittings; reader 3 interpreted the complete exam including 3D and 2D sequences. Accuracies were calculated using arthroscopy as reference standard. McNemar's test (p < 0.05) was used to compare 3D and 2D techniques. RESULTS: The highest diagnostic yield was obtained by reader 3 (accuracies ≥88 %). For the medial meniscus, readers performed better with the 2D technique than with 3D SPACE (accuracies 85-88 % vs. 78-80 %, respectively) (p > 0.05). For the lateral meniscus and ACL, 3D and 2D techniques had similar performance (accuracies ≥93 %). For cartilage lesions, 3D SPACE had significantly lower specificity (p = 0.0156) than the 2D protocol for one reader. CONCLUSION: The conventional 2D TSE acquisition is more reliable than 3D SPACE for comprehensive assessment of the knee at 3.0 T. MAIN MESSAGES: • 3D SPACE is a valuable component of a knee MR protocol at 3 T. • 3D SPACE cannot be used as a single sequence in the MR evaluation of the knee at 3 T. • Knee MR protocols at 3 T should include both 2D and 3D TSE sequences.

Stable or unstable tear of the anterior cruciate ligament of the knee: an MR diagnosis?

PURPOSE: To determine the usefulness of magnetic resonance (MR) imaging to distinguish stable from unstable tears of the anterior cruciate ligament (ACL) of the knee. MATERIALS AND METHODS: MR images of 97 patients with surgically confirmed ACL tear were retrospectively reviewed. According to arthroscopic and clinical examination, these patients had 36 stable and 61 unstable (9 partial and 52 complete) ACL tears. MR images were interpreted by two blinded reviewers and scored with respect to previously reported primary and secondary MR signs of ACL injury. Based on a comprehensive assessment of all the MR findings, ACLs were categorized as being stable or unstable. MR accuracy was calculated considering only primary MR signs and considering both primary and secondary MR signs of ACL injury, separately. Accuracy of each individual primary and secondary MR sign was calculated. RESULTS: Considering only primary MR signs, sensitivity, specificity, and accuracy of MR were 77, 92, and 82%, respectively. Considering both primary and secondary MR signs, sensitivity, specificity, and accuracy of MR were 59, 81, and 67%, respectively. Of all MR signs, discontinuity and abnormal orientation had highest test accuracy (79 and 87%, respectively). Anterior tibial translation, uncovering of the posterior horn of the lateral meniscus, and hyperbuckled PCL were only seen in unstable ACLs (specificity 100%), but these secondary findings had low sensitivity (23%). Bone contusion around the lateral knee compartment was seen in both unstable and stable ACLs (accuracy 64%). CONCLUSION: Previously reported MR imaging signs do not allow accurate distinction between clinically stable and unstable ACL injuries. Anterior tibial translation, uncovering of the posterior horn of the lateral meniscus, and hyperbuckled PCL, if present, are helpful signs in the diagnosis of an unstable tear. The presence of bone marrow edema around the lateral knee compartment is not predictive of ACL insufficiency.

Partial tear of the anterior cruciate ligament of the knee: injury patterns on MR imaging.

PURPOSE: To describe rupture patterns of partial anterior cruciate ligament (ACL) tears on magnetic resonance (MR) imaging. METHODS: MR images of 51 patients with a surgically confirmed partial ACL tear were retrospectively and independently interpreted by 2 experienced, blinded radiologists. Using previously described MR criteria, ACLs were categorized as follows: complete tear, partial tear, isolated anteromedial or posterolateral bundle tear, mucoid degeneration or normal ACL. MR interpretations were compared with the arthroscopic results as the standard of reference. Inter- and intraobserver agreements were determined using kappa (к) coefficients. RESULTS: On MR imaging, ACL injuries were categorized as complete tears (16-23%), partial tears (20-47%), mucoid degeneration (12-27%) or normal ACLs (18-23%). Isolated ACL bundle tears were diagnosed on MR in 6% of our patients. Accuracy of MR for the diagnosis of partial ACL tears was 25-53%. Interobserver agreement was moderate (к = 0.48-0.56). Intraobserver agreement was good (к = 0.72-0.76). CONCLUSION: MR diagnosis of a partial ACL tear is difficult because various tear patterns may be seen. Many partial tears demonstrate MR features that are indistinguishable from complete ACL tear, mucoid ACL degeneration or normal ACL. An isolated ACL bundle tear is infrequently detected on MR images.

Combined arthroscopic techniques in the treatment of non-union of the anterior tibial spine.

We report a non-united tibial spine fracture with instability of the anterior cruciate ligament in a twenty-year-old soccer player. The patient underwent arthroscopy with debridement of scar tissue around the fracture site, reduction and fixation of the bony insertion of the ACL using screw and washer, and femoral notchplasty. More than one year after the initial surgery, the patient fully recovered knee stability and function. We have demonstrated that the additional problems caused by a non-union of a tibial spine fracture can be dealt with in one arthroscopic session.

Three tesla magnetic resonance imaging of the anterior cruciate ligament of the knee: can we differentiate complete from partial tears?

PURPOSE: To determine the ability of 3.0T magnetic resonance (MR) imaging to identify partial tears of the anterior cruciate ligament (ACL) and to allow distinction of complete from partial ACL tears. MATERIALS AND METHODS: One hundred seventy-two patients were prospectively studied by 3.0T MR imaging and arthroscopy in our institution. MR images were interpreted in consensus by two experienced reviewers, and the ACL was diagnosed as being normal, partially torn, or completely torn. Diagnostic accuracy of 3.0T MR for the detection of both complete and partial tears of the ACL was calculated using arthroscopy as the standard of reference. RESULTS: There were 132 patients with an intact ACL, 17 had a partial, and 23 had a complete tear of the ACL seen at arthroscopy. Sensitivity, specificity, and accuracy of 3.0T MR for complete ACL tears were 83, 99, and 97%, respectively, and, for partial ACL tears, 77, 97, and 95%, respectively. Five of 40 ACL lesions (13%) could not correctly be identified as complete or partial ACL tears. CONCLUSION: MR imaging at 3.0T represents a highly accurate method for identifying tears of the ACL. However, differentiation between complete and partial ACL tears and identification of partial tears of this ligament remains difficult, even at 3.0T.