Cortical Suspensory Fixation Research Articles

Suture disc adjustable suspensory fixation device – A cost-effective technique for tibial cortical fixation in cruciate ligament reconstruction

Cruciate ligament reconstruction with adjustable suspensory devices at the femur and tibia allows graft tensioning at both ends, but it is costly due to the tibial suspensory device. To overcome the cost, the author describes a technique where the adjustable suspensory cortical fixation device can be made with a suture disc and an ultra-high-molecular-weight polyethylene suture, which is simple, cost-effective, and making it reproducible even with less experienced arthroscopy surgeons.

A lateral extra-articular tenodesis without additional hardware: Surgical technique and biomechanical comparison with an anatomic anterolateral ligament reconstruction in the augmentation of anterior cruciate ligament reconstruction

BackgroundThe aims of this study were to describe a lateral extra-articular tenodesis (LET) using no additional hardware and compare the tibiofemoral kinematics of anterior cruciate ligament (ACL) reconstruction augmented with either the LET or a standard anatomic anterolateral ligament (ALL) reconstruction using intra-tunnel fixation. MethodsTen cadaveric knees were mounted on a robotic testing system and underwent a kinematic assessment of anterior tibial translation and internal tibial rotation under a simulated pivot-shift in the following states: ACL-intact, ACL-sectioned, ACL-sectioned/anterolateral complex (ALC)-sectioned, ACL-reconstructed/ALC-sectioned, ACL-reconstructed/ALL-reconstructed, and ACL-reconstructed/LET. For the LET, an iliotibial autograft was passed under the fibular collateral ligament and secured to the femur with the pull sutures of the ACL reconstruction femoral cortical suspensory fixation device, positioned at the distal ridge of Kaplan’s fibers. ResultsAnterior tibial translation was restored to normal by ACL reconstruction without meaningful benefit of augmentation with LET or ALL. ACL reconstruction restored internal tibial rotation close to normal between 0° and 30°, but increased internal tibial rotation persisted between 45° and 90°. Augmentation of ACL reconstruction with the LET reduced internal rotation close to normal between 45° and 90°, whereas increased internal rotation persisted after ALL reconstruction. ConclusionACL reconstruction and LET are complementary in controlling tibiofemoral kinematics of knees with a combined ACL and ALC injury: ACL reconstruction restored native tibiofemoral kinematics except for internal rotation at flexion greater than 30°. The increased internal rotation at flexion greater than 30° was restored to normal with an LET, but not with an ALL reconstruction.

...Functional Outcomes After Anterior Cruciate Ligament Reconstruction Using Adjustable Femoral Cortical Suspensory Fixation Device

...Functional Outcomes After Anterior Cruciate Ligament Reconstruction Using Adjustable Femoral Cortical Suspensory Fixation Device

Anterior Cruciate Ligament Reconstruction Using Femoral Cortical Button Fixation: A Case Series of Intraoperative Malpositioning.

Malpositioning of the femoral button is a known technical complication after anterior cruciate ligament (ACL) reconstruction with cortical suspensory fixation. The incidence of malpositioning, as well as the efficacy of methods to prevent malpositioning of cortical suspensory fixation devices, has not been reported. To determine the rate of malpositioned cortical suspensory fixation devices after ACL reconstruction, investigate which intraoperative technique yields the lowest rate of malpositioning, and determine the return-to-duty rate for active-duty service members with malpositioned buttons and the revision rate for malpositioned buttons. Case series; Level of evidence, 4. The records of patients who underwent primary ACL reconstruction with a cortical suspensory fixation device between 2008 and 2018 were reviewed at our institution. Postoperative radiographs were reviewed for evidence of malpositioned femoral buttons. Malpositioned buttons were classified as (1) fully positioned in the bone tunnel, (2) partially positioned in the bone tunnel, (3) >2 mm from cortical bone, or (4) deployed over the iliotibial band. Operative reports were reviewed to determine the intraoperative methods undertaken to verify the button position. The rate of malpositioned cases with subjective instability and revision surgery performed were determined. The ability of patients to return to full military duty was reviewed for active-duty personnel. A total of 1214 patients met the inclusion criteria. A 3.5% rate (42 cases) of malpositioned cortical suspensory fixation devices (femoral buttons) was identified. For patients with malpositioned buttons, 7 (16.7%) patients underwent revision surgery in the immediate postoperative period. Techniques used to avoid malpositioning included direct arthroscopic visualization, direct open visualization, intraoperative fluoroscopy, and first passing the button through the skin before positioning on the femoral cortex. There was a 4.6% malposition rate using direct arthroscopic visualization and a 5.1% malposition rate using passage of the button through the skin, while no malpositioning occurred with intraoperative fluoroscopy or direct open visualization (P < .05). Overall, 12 (28.6%) patients with malpositioned buttons ultimately underwent revision surgery. Despite having been diagnosed with malpositioned buttons, 21 (63.6%) active-duty members were able to return to full duty. Malpositioning of femoral buttons during ACL reconstruction occurred in 3.5% of patients in this series. The techniques of intraoperative fluoroscopy and direct open visualization are encouraged to prevent malpositioning.

Comparative fixation devices for preventing migration of the proximal tibiofibular joint during tibial lengthening: a tether versus screw fixation

BackgroundWhen lengthening the tibia segment using motorized internal lengthening nails (MILN), undesired distal migration of the proximal fibula segment is prevented by tibiofibular stabilization, traditionally using a screw. A tightened cortical suspensory fixation rope (tether) is an alternative option, but its appropriateness has never been studied. The primary outcome was comparing the amount of proximal fibular migration between patients who were stabilized with either a tether or a screw. The secondary outcome was to evaluate the effect of fibular migration on the clinical outcome between both groups.MethodsA retrospective study was conducted on patients who underwent tibial lengthening with MILN between April 2016 and June 2022. Two cohorts were compared: 18 limbs with tether fixation versus 29 limbs with screw fixation. Data on the patient's age, sex, etiologies, and clinical outcomes were collected. Radiographic measurements included the lengthening distance and the amount of proximal fibular migration.ResultsIn total, 47 limbs from 41 patients, with average age 35.01 ± 13.72 years old. There were 28 males (68.29%) and 13 females (31.71%). The tether group demonstrated a statistically significant greater distance of migration than the screw group (p < 0.001), with an average migration distance of 8.39 ± 5.09 mm and 2.59 ± 3.06 mm, respectively. No correlation was found between the amount of tibial lengthening and the distance of proximal fibular migration in both the tether group (p = 0.96) and the screw group (p = 0.32). There was no significant difference in the change of knee extension between both groups (p = 0.3), and no patients reported knee pain or tightness.ConclusionA screw provides better resistance to proximal tibiofibular joint migration during MILN lengthening, but the difference appears clinically inconsequential. Either option appears suitable.

Cortical suspensory button fixation has superior biomechanical properties to knotless anchor suture in anterior cruciate ligament repair: a biomechanical study

The purpose of our biomechanical study was to assess load-to-failure, stiffness, gap formation following cyclic loading, and the failure mechanism for anterior cruciate ligament (ACL) repair comparing the cortical suspensory button and knotless anchor suture. Eight Thiel’s embalmed paired cadaveric knees from four cadavers were dissected. The specimens were assigned to undergo ACL repair either with cortical suspensory button or with knotless anchor suture. The Instron machine replicates cyclic loading and then determines the gap formation. Traction was applied until failure. The load-to-failure, stiffness, and modes of failure in both groups were recorded. The load-to-failure, stiffness, and gap formation were compared between the two groups using the student's t-test. The mean load-to-failure in the cortical suspensory button group was significantly higher than the knotless anchor suture group (212.96 ± 54.57 vs 44.57 ± 20.80, p value < 0.01). No statistically significant difference was found regarding gap formation following cyclic loading and stiffness between the cortical suspensory button group and the knotless anchor suture group. This biomechanical study showed a higher load-to-failure for the ACL repair with cortical suspensory button compared to ACL repair with knotless anchor suture, while no statistically significant difference was found regarding the gap formation following cyclic loading and the stiffness. The load-to-failure in both cortical suspensory button and knotless anchor suture are below regular daily activity load. Thus, an internal brace or external support is recommended during rehabilitation.

Posterior Cruciate Ligament Reconstruction With Quadriceps Tendon–Patellar Bone Autograft

Multiple surgical techniques for posterior cruciate ligament reconstruction have been described and subsequently scrutinized. We describe a surgical technique using full-thickness quadriceps tendon–patellar bone autograft in single-bundle, all-inside posterior cruciate ligament reconstruction that offers the following advantages over traditional technique: This technique mitigates the risk of tunnel widening and convergence while preserving bone stock, eliminating the killer turn, allowing for suspensory cortical fixation to optimize stabilization, and using a bone plug that allows for faster graft incorporation.

Morphological Changes in the Tibial Tunnel After ACL Reconstruction With the Outside-In Technique and Adjustable Suspensory Fixation.

Anterior cruciate ligament reconstruction (ACLR) using the complete tibial tunnel technique and adjustable-loop cortical suspensory fixation is known to leave a "dead space" that holds the loop device in the tibial tunnel. The consequence of the dead space and its effect on graft healing are still uncertain. To investigate morphological changes in the tibial tunnel and their effect on graft healing, and to identify factors affecting bone healing in the tibial loop tunnel after ACLR with a quadrupled semitendinosus tendon autograft using adjustable suspensory fixation. Case series; Level of evidence, 4. Included were 48 patients (34 male, 14 female; mean age, 25.2 ± 5.6 years) who underwent ACLR with a quadrupled semitendinosus tendon autograft using adjustable suspensory fixation. To evaluate tibial tunnel morphology, computed tomography was performed at 1 day and 6 months postoperatively. At 1 year postoperatively, graft healing was assessed on magnetic resonance imaging using the graft signal-to-noise quotient (SNQ). Multivariate regression and correlation analyses were performed to determine any associations between volumetric changes in bone healing and operative variables. At 6 months after ACLR, a mean of 63.2% of the tibial loop tunnel was filled by bone. Multivariate regression analysis showed that remnant preservation was significantly associated with the loop tunnel filling rate (P < .001). At 1 year after ACLR, the tibial loop tunnel was almost completely closed (98.5%). There were no correlations between loop tunnel volume and graft integration or graft SNQ. A significant but weak correlation was found between graft tunnel volume and intratunnel graft SNQ (P = .10) as well as integration grade in the tibial tunnel (P = .30). Excellent bone filling in the tibial loop tunnel was seen at 1 year after ACLR. Remnant preservation was significantly associated with the loop tunnel filling rate. A weak correlation was found between graft tunnel volume and intratunnel graft SNQ as well as integration grade in the tibial tunnel.

Teres Major and Latissimus Dorsi Repair With Biceps Tenodesis Utilizing Cortical Suspensory Fixation Buttons

Teres major (TM) and latissimus dorsi (LD) ruptures are relatively rare in the general population and have primarily been observed in overhead throwing athletes. Although the gold standard of care has traditionally been nonoperative, surgical repair of TM and LD tendon ruptures has become increasingly prevalent in high-level athletes who fail to return to play. Literature is scarce regarding operative repair of these tendon ruptures. Therefore, our goal is to present a potential technique for open repair to surgeons who may be faced with this unique orthopedic injury. Our technique details an open TM and LD repair, in addition to biceps tenodesis, using cortical suspensory fixation buttons with a combined anterior and posterior approach.

Adjustable-Loop Cortical Suspensory Fixation Results in Greater Tibial Tunnel Widening Compared to Interference Screw Fixation in Primary Anterior Cruciate Ligament Reconstruction.

Background: Although the use of adjustable-loop suspensory fixation has increased in recent years, the influence of the shortcomings of suspensory fixation, such as the bungee-cord or windshield-wiper effects, on tunnel widening remains to be clarified. Hypothesis/Purpose: The purpose of this study was to compare adjustable-loop femoral cortical suspensory fixation and interference screw fixation in terms of tunnel widening and clinical outcomes after anterior cruciate ligament reconstruction (ACLR). We hypothesized that tunnel widening in the adjustable-loop femoral cortical suspensory fixation (AL) group would be comparable to that in the interference screw fixation (IF) group. Methods: This study evaluated patients who underwent primary ACLR at our institution between March 2015 and June 2019. The femoral and tibial tunnel diameters were measured using plain radiographs in the immediate postoperative period and 2 years after ACLR. Tunnel widening and clinical outcomes (Lysholm score, 2000 International Knee Documentation Committee subjective score, and Tegner activity level) were compared between the two groups. Results: There were 48 patients (mean age, 29.8 ± 12.0 years) in the AL group and 44 patients (mean age, 26.0 ± 9.5 years) in the IF group. Tunnel widening was significantly greater in the AL group than that in the IF group at the tibia anteroposterior (AP) middle (2.03 mm vs. 1.32 mm, p = 0.017), tibia AP distal (1.52 mm vs. 0.84 mm, p = 0.012), tibia lateral proximal (1.85 mm vs. 1.00 mm, p = 0.001), tibia lateral middle (2.36 mm vs. 1.03 mm, p < 0.001), and tibia lateral distal (2.34 mm vs. 0.85 mm, p < 0.001) levels. There were no significant differences between the two groups with respect to femoral tunnel widening and clinical outcomes. Conclusions: Tibial tunnel widening was significantly greater in the AL group than in the IF group at 2 years after primary ACLR. However, the clinical outcomes in the two groups were comparable at 2 years.

Arthroscopic Visualization of Femoral Cortical Button Deployment During Anterior Cruciate Ligament Reconstruction

Background: Up to 25% of femoral cortical suspensory fixation devices are reported to be deployed inappropriately during anterior cruciate ligament (ACL) reconstruction. Most techniques for visualizing suspensory button deployment reported in the literature are for adjustable loop buttons and outside-in femoral tunnel technique. Intraoperative radiographs are inconvenient and involve exposure to radiation. No “gold standard” technique for visualization of femoral cortical button deployment has been described yet. Indications: This technique can be employed for all patients requiring ACL reconstruction surgery. Technique Description: The femoral tunnel is prepared from the anteromedial portal. With the knee in flexion, a beath pin loaded with a suture loop is passed via the anteromedial portal through the femoral tunnel; the eyelet of the pin with the suture loop is retained in the femoral tunnel. The knee is extended without fear of bending the beath pin. The arthroscope is shifted into the lateral gutter. An outside-in lateral parapatellar portal is made at the level of the center of the patella, 1 cm lateral to its lateral edge. The joint capsule and soft tissues in the lateral gutter are resected using a shaver. The beath pin is identified without fear of lacerating the suture loop. The exit point of the pin depends on the knee flexion at the time of femoral tunnel preparation, and more flexion results in more anterior pin exit and vice versa. The rest of the surgery is performed as planned. The definitive sutures of the desired femoral cortical suspensory device are passed from the tibial tunnel into the femoral tunnel. The arthroscope is then positioned in the lateral gutter and the cortical button is deployed appropriately under vision, onto the lateral femoral cortex. If required, the cortical button can be manipulated to seat it appropriately, using an instrument from the lateral parapatellar portal. The remainder of the surgery is performed as per the surgeon’s preference. Results: We routinely perform this step during ACL reconstruction. It adds 2 to 4 minutes to the surgical time. We have not encountered any complications of this procedure. Discussion/Conclusion: This maneuver is effective in facilitating appropriate deployment of femoral cortical suspensory devices under vision.

Posterolateral Corner Reconstruction Using Double Femoral Fixation With Adjustable Loop Cortical Suspension and Interference Screw

Background: The posterolateral corner (PLC) of the knee is a complex anatomic region of the knee comprising the popliteus tendon, the popliteofibular ligament (PFL), and the fibular collateral ligament (FCL). Treatment of PLC injuries is based on the degree of varus and rotational instability on preoperative examination and is recommended in grade 3 injuries.1,6 Technique Description: The key concept of this new surgical technique is to use adjustable loop cortical suspensory fixation implants for initial femoral fixation of the popliteus and the FCL grafts. This allows for individual tensioning of the grafts prior to definitive fixation with an interference screw. An anatomic fibular tunnel is initially created, followed by popliteus and FCL anatomic femoral socket drilling. A TightRope RT implant is attached to the popliteus end of the graft and secured through a bone tunnel on the medial femoral cortex initially. The popliteus end of the graft is then pulled into the femoral socket before tunneling the graft through the fibular tunnel. A second TightRope RT implant is secured to the FCL end of the graft before securing it to the medial femoral cortex through a bone tunnel and pulling the graft into the drilled femoral socket. An interference screw is first used to secure the graft at the fibular tunnel. The knee is then taken to 60° where the TightRope device is used to remove residual creep and optimize final tensioning prior to final fixation with interference screw in femoral socket. With the knee at 30° of flexion, neutral rotation, and slight valgus, the same steps are repeated for FCL graft. A posterolateral capsular shift is completed for additional stability. Results: Residual posterolateral corner instability or failure after reconstruction surgery has been reported in 6% to 9.4% of surgical reconstruction case.2,3,5 The use of cortical suspensory devices in PLC reconstructions allows independent dialing of optimal graft tension for both the popliteus and FCL reconstruction before final interference screw fixation, therefore presumably limiting any residual creep and allowing for a double femoral fixation of the graft. Discussion: We describe a novel technique for posterolateral corner reconstruction which allows for optimal and individual tensioning of the structures of the posterolateral corner. Given the technique still uses well-described and validated graft choices and anatomic landmarks for reconstruction, we expect this new technique to allow for similar if not improved outcomes when compared with current gold standard.4

Tibial tunnel expansion does not correlate with four-strand graft maturation after ACL reconstruction using adjustable cortical suspensory fixation.

Anterior cruciate ligament reconstruction (ACLR) using a short, quadrupled semitendinosus (ST-4) autograft, fixed with an adjustable suspensory fixation (ASF), has several potential advantages. However, the construct is suspected to generate micromotion, tunnel widening and poor graft maturation. The aim of this study was to evaluate post-operative tibial tunnel expansion, graft maturation and clinical outcomes for this type of ACLR. One-hundred and forty-nine patients were reviewed at a minimum of 2 years following 4-ST ACLR, mean 25.6 ± 3.5months [24-55], with clinical follow-up and MRI scans. Graft maturity of the intra-articular part of the graft and the tibial tunnel portion was assessed using Signal-to-Noise Quotient (SNQ) and Howell score. Tibial tunnel expansion, bone-graft contact and graft volume in the tibial tunnel were calculated from the MRI scans. Mean tibial tunnel expansion was 13 ± 16.5% [12-122]. Mean SNQ for graft within the tibial tunnel was 3.8 ± 7.1 [ - 7.7 to 39] and 2.0 ± 3.5 [ - 14 to 17] for the intra-articular portion of the graft. The Howell score for graft within the tibial tunnel was 41% Grade I, 37% Grade 2, 20% Grade 3, 2% grade 4, and for the intra-articular part 61% Grade 1, 26% Grade 2, 13% Grade 3 and 1% Grade 4. The mean tibial tunnel bone-graft contact was 81 ± 23% [0-100] and mean graft volume was 80 ± 22% [0-100]. No correlation was found between tibial tunnel expansion and graft maturity assessed at both locations. Graft maturity was correlated with higher graft-bone contact and graft volume in the tibial tunnel (p < 0.05). ST-4 ACLR with ASF had low levels of tunnel enlargement at 2years. No correlation was found between graft maturation and tibial tunnel expansion. Graft maturity was correlated with graft-bone contact and graft volume in the tibial tunnel. Level III.

Medial Ulnar Collateral Ligament Reconstruction: A Dual Docking, 4-Ply Reconstructive Technique

Background: Ulnar collateral ligament injuries are common in the overhead-throwing athlete as the anterior band of this ligament is the primary soft tissue static stabilizer to valgus stress during a throwing motion. Various surgical techniques have been described over the past 30 years to address these injuries including Jobe, modified Jobe, docking, 3-stranded docking, Graftlink, and anatomic repairs with good to excellent results. Nevertheless, modifications to these techniques may increase the strength and survival of the reconstruction, which may expedite and optimize postoperative rehabilitation and return to play. Indications: This is a reproducible technique that provides excellent outcomes. We believe a 4-ply construct, with the addition of a high tensile strength suture tape, may provide superior biomechanical properties compared to other reconstructive techniques. Biomechanical testing for this technique is currently underway. Technique Description: Medial ulnar collateral ligament reconstruction using a gracilis autograft passed from proximal to distal, secured at the ulna with a cortical button tension loop construct, and then repassed from distal to proximal with the addition of a high strength suture in parallel to function as an internal brace. Together, this creates a reinforced, 4-ply, ulnar collateral ligament reconstruction with excellent tensile strength. Other advantages of this technique are that it avoids bony bridge fracture between ulnar tunnels, it preserves ulnar bone stock, creates a more anatomic insertion at the sublime tubercle and provides a simple method to tension the entire graft construct. Results: The expected outcomes from this procedure are consistently positive with recent literature reporting greater than 90% of patients having an excellent outcome and over 80% of overhead athletes returning to sport at or above previous level. Conclusion: This specific technique provides a rigid, high-tensile strength reconstruction with excellent outcomes and a high percentage of return to play. Additionally, this technique avoids various technical pitfalls by utilizing cortical button suspensory fixation at the ulna which minimizes complications such as ulnar tunnel conversion and iatrogenic injury to the ulnar nerve when drilling posterior to the sublime tubercle as is necessary with other techniques.

A Comparative Study on Functional Outcomes of Fixed Versus Adjustable Length-Loop Device for Femoral Fixation of Graft in Anterior Cruciate Ligament Reconstruction

A Comparative Study on Functional Outcomes of Fixed Versus Adjustable Length-Loop Device for Femoral Fixation of Graft in Anterior Cruciate Ligament Reconstruction

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

BackgroundThe 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. MethodsTwenty-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. ResultsACL 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. ConclusionACL 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 EvidenceControlled Laboratory Study.

ACL Study Group presents the global trends in ACL reconstruction: biennial survey of the ACL Study Group

ObjectivesThe primary objective of this survey was to gauge the current global trends in anterior cruciate ligament reconstruction (ACLR) as reported by the members of the Anterior Cruciate Ligament (ACL) Study Group (SG).MethodsA survey was created and distributed among the members of the ACL SG consisting of 87 questions and 16 categories related to ACLR, including member demographics, preoperative management, primary ACLR techniques and graft choice, use of concomitant procedures and biological augmentation, postoperative rehabilitation, and more.ResultsThe survey was completed by the 140 members of the ACL SG. Fifty per cent of members are from Europe, 29% from the USA, 15% from the Asia-Pacific and the remaining 6% are from Latin America, the Middle East, New Zealand and Africa. Most (92%) do not believe there is a role for non-operative management of ACL tears in higher level athletes; conversely, most agree there is a role for non-operative management in lower impact athletes (92%). A single-bundle (90%) technique with hamstring autograft (53%) were most common for primary ACLR. Tunnel position varied among respondents. Sixty-one per cent do not use allograft for primary ACLR. Fifty per cent of respondents use cortical suspensory fixation on the femur, with variable responses on the tibia. Most (79%) do not use biologics in primary ACLR, while 83% think there is a selective role for extra-articular augmentation in primary ACLR. Fifty per cent prefer bone-tendon-bone autograft for revision ACLR and extra-articular augmentation is more commonly used (13% always, 26% often) than in primary ACLR (0% always, 15% often). A majority (53%) use a brace after primary ACLR. The most common responses for minimal time to return to play after primary ACLR were 6–8 months (44%) and 8–12 months (41%).ConclusionWe presented the thoughts and preferences of the ACL SG on the management of ACL injuries. This survey will help to facilitate an ongoing discussion with regard to ACLR by providing global insights into the current surgical trends in ACLR.Level of evidenceLevel V, Expert Opinion.

Differences in artificial ligament graft osseointegration of the anterior cruciate ligament in a sheep model: a comparison between interference screw and cortical suspensory fixation.

BackgroundInterference screws are the most common femoral fixation for anterior cruciate ligament (ACL) reconstruction with polyethylene terephthalate (PET) artificial ligaments. However, interference screws have several disadvantages, such as the risk of one tunnel blowout and damage to the graft. Suspensory fixations have the advantages of high tensile strength and promotion of graft bone contact. The purpose of this study was to compare PET artificial ligament graft osseointegration between interference screw fixation (ISF) and cortical suspensory fixation (CSF) for ACL reconstruction.MethodsForty sheep underwent ACL reconstruction of the right knee with PET artificial ligament. The graft was fixed with ISF or CSF for femoral fixation. Animals were randomly assigned to the ISF (n=20) or the CSF (n=20) groups. The sheep were sacrificed at 3 or 12 months postoperatively for biomechanical tests, micro computed tomography (micro-CT) scans, and histological assessments.ResultsThe mean load-to-failure between the CSF group (836±355 N) appeared higher than that of the ISF group (604±277 N) at 3 months, but no significant difference was detected between the groups (P=0.24). At 12 months, there was also no significant difference in load-to-failure between the CSF and ISF groups (1,194±350 vs. 1,097±764 N; P=0.78). According to the micro-CT scan results, the femoral bone tunnel diameter of the ISF group appeared larger than that of the CSF group at 3 months (12±1 vs. 10±1 mm; P=0.02) and similar to that of the CSF group at 12 months (12±1 vs. 11±2 mm; P=0.38). Furthermore, histological results showed that at the graft-tunnel interface of the femoral tunnel aperture, disoriented fibers formed in the ISF group while oriented and dense fibers formed in the CSF group.ConclusionsACLR with synthetic ligament by cortical suspension devices with adjustable loops demonstrated a better graft-bone healing capacity at the femoral tunnel aperture compared with that from titanium interference screws over 12 months postoperatively. No significant difference was found in biomechanical strength between the two fixation methods during the early healing stage.

Clinical Reliability of Adjustable Femoral Cortical Suspensory Fixation in Anterior Cruciate Ligament Reconstruction and Correlation of Clinical Outcomes With Demographic and Perioperative Factors.

Background and objectiveThe primary goal of anterior cruciate ligament reconstruction (ACLR) is to protect the initial graft fixation against heavy loads encountered during the rehabilitation phase. The purpose of this study was to evaluate the functional outcomes (Lysholm score) and laxity [anterior tibial translation (ATT), anterior drawer test, Lachman test, and pivot shift test] of ACLR with adjustable-loop femoral cortical suspensory fixation (CSF) and tibial interferences crew fixation.MethodsThis study included 100 patients who underwent primary ACL reconstruction using quadruple hamstring grafts secured with TightRope® (Arthrex Inc, Naples, FL) femoral fixation and an interference screw on the tibial end. Six patients were excluded from the final analysis (four lost to follow-up, one suffered re-injury, and one had septic arthritis). The remaining 94 patients were evaluated for laxity and functional outcomes preoperatively, as well as at one, six, and 12 months postoperatively. Regression analysis was performed to determine the association between outcomes and 11 independent variables. This was designed as a prospective cohort study (level of evidence: II).ResultsThe mean age of the participants was 28.46 ± 7.01 years. The median preoperative Lysholm knee score of 49 (mean ± SD: 48.2 ± 5.42) improved to 93 (92.7 ± 2.1) at six months and 98 (97.6 ± 2.1) at the one-year follow-up. The improvement was found to be statistically significant (p<0.01). The median ATT was 10 mm preoperatively, which decreased to 2 mm at one month, remained the same at six months, and rose to 3 mm at the one-year follow-up. ATT was found significantly reduced at one month postoperatively (p<.001) and did not show any significant further changes at subsequent follow-ups (p>0.05). Multiple linear regression revealed that one-year postoperative ATT (Rolimeter, Aircast Europa, Stephanskirchen, Germany) was independent of all demographic and perioperative variables tested.ConclusionQuadrupled hamstring graft ACLR with adjustable-loop fixation showed excellent subjective and objective outcomes with no residual laxity or failure of graft over mid-term follow-up. Postoperative laxity was not correlated with graft and tunnel dimensions.

Original study: early patient-reported functional outcome of all-inside ACL reconstruction as compared to anteromedial portal technique.

Anteromedial portal technique (AMP) using hamstring autograft is a popular technique of arthroscopic ACL reconstruction allowing anatomical placement of femoral. In this technique, a cortical suspensory fixation of graft is used on the femoral side and interference screw fixation on the tibial side using a complete bone tunnel. All-inside translateral technique is a recently introduced technique which uses a closed loop of quadrupled semitendinosus graft with an adjustable cortical suspensory fixation on both sides allowing optimum tensioning of graft and near-complete filling of retrosockets created by the flip cutter on both femoral and tibial sides. With its proposed but unproven benefits, our study was planned to compare the two techniques. A total of 80 young active males requiring ACL reconstruction surgery were equally randomized to AMP and All-inside technique. The primary objective of the study was to compare the ability to return to pre-injury level of activity using Tegner activity scale and patient-reported outcome using new Knee Society Score (KSS) at two years of follow-up. The mean improvement in Tegner score was significantly better (p = 0.0005) in all-inside group (2.34 ± 0.97) as compared to AMP group (1.5 ± 1.30). Among components of new KSS, patient satisfaction was better in all-inside group. All-inside ACL reconstruction provides a better chance of return to pre-injury level of activity with accompanied patient satisfaction as compared to AMP technique at two years of follow-up. Level I, therapeutic study.