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Bastos R, Santos CF, Andrade R, Valente C, Pereira R, Parente M, Jorge RN, Espregueira-Mendes J. InternalBrace behavior at different orientation placements during anterior cruciate ligament repair: A computational finite element simulation. J ISAKOS 2025; 11:100847. [PMID: 40054774 DOI: 10.1016/j.jisako.2025.100847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 02/26/2025] [Accepted: 02/28/2025] [Indexed: 03/26/2025]
Abstract
OBJECTIVES InternalBrace™ technique (Arthrex, Naples, USA) has been applied in anterior cruciate ligament repairs in recent years as an alternative to the anterior cruciate ligament reconstruction, with several advantages. The present study aimed to investigate the optimal location to place the InternalBrace during surgery to reduce the stress on the repaired anterior cruciate ligament. METHODS In silico study of a finite element model of the knee and the anterior cruciate ligament was developed to test the position of the InternalBrace at the repaired anterior cruciate ligament. Five different InternalBrace positions inside the anterior cruciate ligament were analysed under two conditions: with and without damage. Stress and strain in both the InternalBrace and the anterior cruciate ligament were evaluated and compared with a healthy condition (without InternalBrace). The computational simulations using the finite element method were performed under predefined boundary conditions observed during anterior cruciate ligament tears. RESULTS The peak strain (8.1%) was obtained in the damaged anterior cruciate ligament compared with a 4.8% strain in the undamaged anterior cruciate ligament in the case without InternalBrace with the same boundary conditions applied. The use of InternalBrace showed a decrease in the deformations of the anterior cruciate ligament, mainly when the InternalBrace was applied in the anteromedial bundle or crossed from the anterior cruciate ligament anteromedial tibial footprint to posterolateral femoral footprint. CONCLUSION The InternalBrace placement through the anteromedial bundle or crossed from the anteromedial tibial footprint to posterolateral femoral footprint showed the lowest peak stress and peak strain in the anterior cruciate ligament, with forces and deformation in the anterior cruciate ligament being partially shifted to the InternalBrace. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Ricardo Bastos
- Dom Henrique Research Centre, Porto, Portugal; Clínica Espregueira - FIFA Medical Centre of Excellence, Porto, Portugal; Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
| | - Carla F Santos
- INEGI - Science and Innovation in Mechanical and Industrial Engineering, Porto, Portugal
| | - Renato Andrade
- Dom Henrique Research Centre, Porto, Portugal; Clínica Espregueira - FIFA Medical Centre of Excellence, Porto, Portugal; Porto Biomechanics Laboratory (LABIOMEP), Faculty of Sports, University of Porto, Portugal
| | - Cristina Valente
- Dom Henrique Research Centre, Porto, Portugal; Clínica Espregueira - FIFA Medical Centre of Excellence, Porto, Portugal
| | - Rogério Pereira
- Dom Henrique Research Centre, Porto, Portugal; Clínica Espregueira - FIFA Medical Centre of Excellence, Porto, Portugal; Health Sciences Faculty, University Fernando Pessoa, Porto, Portugal
| | - Marco Parente
- FEUP- Faculty of Engineering of the University of Porto, Porto, Portugal
| | - Renato Natal Jorge
- INEGI - Science and Innovation in Mechanical and Industrial Engineering, Porto, Portugal; FEUP- Faculty of Engineering of the University of Porto, Porto, Portugal
| | - João Espregueira-Mendes
- Dom Henrique Research Centre, Porto, Portugal; Clínica Espregueira - FIFA Medical Centre of Excellence, Porto, Portugal; School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal; 3B's Research Group - Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Barco, Guimarães, Portugal.
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Strassman AK, Stokes DJ, Sanchez RA, Shinsako KK, Smith PA, DiFelice GS, Frank RM. Anterior Cruciate Ligament Repair Using a Re-tensionable All-Suture Construct. Arthrosc Tech 2024; 13:102890. [PMID: 38584624 PMCID: PMC10995730 DOI: 10.1016/j.eats.2023.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/02/2023] [Indexed: 04/09/2024] Open
Abstract
Anterior cruciate ligament (ACL) tears are among the most common injuries to the knee. With recent improvements in imaging that allow for more precise identification of ACL tear patterns, improved techniques for repair, and advancements in biological augmentation, there has been a re-emerging interest in primary ACL repair, especially for acute proximal ACL tears. This article aims to describe a surgical technique for primary ACL repair using a re-tensionable all-suture-based construct.
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Affiliation(s)
| | - Daniel J Stokes
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Denver, Colorado, U.S.A
| | | | - Kevin K Shinsako
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Denver, Colorado, U.S.A
| | | | | | - Rachel M Frank
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Denver, Colorado, U.S.A
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Bachmaier S, Smith PA, Hammoud S, Ritter D, Hauck O, Wijdicks CA. Stabilization and Gap Formation of Adjustable Versus Fixed Primary ACL Repair With Internal Brace: An in Vitro Full-Construct Biomechanical Cadaveric Study. Orthop J Sports Med 2023; 11:23259671231201462. [PMID: 37786477 PMCID: PMC10541754 DOI: 10.1177/23259671231201462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/19/2023] [Indexed: 10/04/2023] Open
Abstract
Background A knotless, tensionable primary anterior cruciate ligament (ACL) repair system preloaded with an internal brace has been released. Currently, there is no biomechanical data on the stabilization and gap formation behavior of the adjustable system when compared with fixed repairs in human ACL tissue. Hypothesis That knotless adjustable suture repair with an internal brace would provide overall higher construct stability and greater load share on the ACL with less gap formation compared with fixed repair. Study Design Controlled laboratory study. Methods Human cadaveric knees were utilized for internal braced ACL repair constructs (each group n = 16). Two fixed groups consisting of a single-cinch loop (SCL), cortical button (SCL group), and knotless suture-anchor (anchor group) were compared with an SCL-adjustable loop device (SCL-ALD) group. Testing was performed at 4 different peak loads (50, 150, 250, 350 N) over 4000 cycles at 0.75 Hz including suture repair preconditioning (10 cycles at 0.5 Hz) for SCL-ALD. Specimens were ultimately pulled to failure with a cut internal brace. The final loading situation of the construct and ACL repair with gap formation and ultimate strength were evaluated. Results Peak elongation at various peak loads showed a significantly higher (P < .001) stabilization of SCL-ALD when compared with both fixed groups. There was a significantly higher (P < .001) load share of SCL-ALD, especially at lower loads (48% of 50 N), and the gap formation remained restricted up to 250 N. With only a little load share on the fixed constructs (<6%) at lower loads (50, 150 N), gap formation in these groups started at a load of 150 N, leading to significantly higher gaps (P < .001). The ultimate failure load for SCL-ALD and anchor groups was significantly increased (P < .001) as compared with SCL. The stiffness of SCL-ALD (62.9 ± 10.6 N/mm) was significantly increased (P < .001). Conclusion Internal braced knotless adjustable fixation for ACL repair with preconditioning of the suture repaired ligament increased the overall stabilization with higher load share on the ACL and restricted gap formation (<0.5 mm up to 350 N) compared with fixed suture repair. All internal braced repairs restored stability according to native ACL function. Clinical Relevance Adjustable ACL repair improved the mechanical characteristics and reduced gap formation, but the overall clinical significance on healing remains unclear.
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Affiliation(s)
| | | | - Sommer Hammoud
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Daniel Ritter
- Arthrex Department of Orthopedic Research, Munich, Germany
| | - Oliver Hauck
- Arthrex Department of Orthopedic Research, Munich, Germany
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Itthipanichpong T, Tangboonnitiwong N, Limskul D, Tanpowpong T, Kuptniratsaikul S, Thamrongskulsiri N. Arthroscopic Anterior Cruciate Ligament Primary Repair With Synthetic Augmentation and Fixation With the Knotless Suture Anchor. Arthrosc Tech 2023; 12:e1009-e1013. [PMID: 37533897 PMCID: PMC10390709 DOI: 10.1016/j.eats.2023.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 02/15/2023] [Indexed: 08/04/2023] Open
Abstract
An anterior cruciate ligament (ACL) tear is one of the most common ligament injuries in athletes. The arthroscopic ACL reconstruction procedure is the gold standard for treatment. However, the improvement in injury classification and suture materials has subsequently made arthroscopic ACL primary repair an alternative surgical treatment option. This Technical Note describes an arthroscopic ACL primary repair with synthetic augmentation made of several high-strength sutures and fixation with the knotless suture anchor. The reinforced synthetic material acts as a structural tie to support the ACL while it heals.
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Affiliation(s)
- Thun Itthipanichpong
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Napol Tangboonnitiwong
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Danaithep Limskul
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Thanathep Tanpowpong
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Somsak Kuptniratsaikul
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
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Takahashi T, Watanabe S, Ito T. Current and future of anterior cruciate ligament reconstruction techniques. World J Meta-Anal 2021; 9:411-437. [DOI: 10.13105/wjma.v9.i5.411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/09/2021] [Accepted: 10/25/2021] [Indexed: 02/06/2023] Open
Abstract
In recent years, anterior cruciate ligament (ACL) reconstruction has generally yielded favorable outcomes. However, ACL reconstruction has not provided satisfactory results in terms of the rate of returning to sports and prevention of osteoarthritis (OA) progression. In this paper, we outline current techniques for ACL reconstruction such as graft materials, double-bundle or single-bundle reconstruction, femoral tunnel drilling, all-inside technique, graft fixation, preservation of remnant, anterolateral ligament reconstruction, ACL repair, revision surgery, treatment for ACL injury with OA and problems, and discuss expected future trends. To enable many more orthopedic surgeons to achieve excellent ACL reconstruction outcomes with less invasive surgery, further studies aimed at improving surgical techniques are warranted. Further development of biological augmentation and robotic surgery technologies for ACL reconstruction is also required.
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Affiliation(s)
- Toshiaki Takahashi
- Department of Sports and Health Science, Ehime University, Matsuyama 790-8577, Ehime, Japan
| | - Seiji Watanabe
- Department of Orthopedic Surgery, Ehime University Graduate School of Medicine, Toon 791-0295, Ehime, Japan
| | - Toshio Ito
- Department of Orthopaedic Surgery, Murakami Memorial Hospital, Saijo 793-0030, Ehime, Japan
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Kobayashi EF, Tang K, Grant JA. Is ACL Repair Really Back? A Review of Modern Techniques. OPER TECHN SPORT MED 2021. [DOI: 10.1016/j.otsm.2021.150828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Author Reply to "Regarding 'Suture Tape Augmentation Has No Effect on Anterior Tibial Translation, Gap Formation, or Load to Failure of Anterior Cruciate Ligament Repair: A Biomechanical Pilot Study'". Arthroscopy 2021; 37:1374-1375. [PMID: 33896491 DOI: 10.1016/j.arthro.2021.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 03/11/2021] [Indexed: 02/02/2023]
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Smith PA, DiFelice GS, Douoguih WA, Sonnery-Cottet B, Pace JL. Regarding "Suture Tape Augmentation Has No Effect on Anterior Tibial Translation, Gap Formation, or Load to Failure of Anterior Cruciate Ligament Repair: A Biomechanical Pilot Study". Arthroscopy 2021; 37:1372-1374. [PMID: 33896490 DOI: 10.1016/j.arthro.2021.03.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/11/2021] [Indexed: 02/02/2023]
Affiliation(s)
| | | | - Wiemi A Douoguih
- MedStar Washington Hospital Center, Washington, District of Columbia, U.S.A
| | | | - J Lee Pace
- Connecticut Children's Specialty Group, Hartford, Connecticut, U.S.A
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Smith PA. Editorial Commentary: Repair the Anterior Cruciate Ligament When You Can: Add Suture Tape Augmentation and Dress for Success. Arthroscopy 2021; 37:1242-1244. [PMID: 33812527 DOI: 10.1016/j.arthro.2020.12.218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 12/17/2020] [Indexed: 02/02/2023]
Abstract
Preserving the native anterior cruciate ligament (ACL) through primary repair has seen a resurgence over the past few years-rightfully so-given the inherent advantages of repairing the ACL over reconstruction. The issue is how best to repair the ACL and protect it to optimize healing. Suture tape augmentation techniques have shown promising low failure rates, and recent biomechanical studies have demonstrated benefits of the suture tape and optimal fixation methods for ACL repair. So, I believe it is time for orthopaedic surgeons to strongly consider routine suture tape augmentation use for improved outcomes with primary ACL repair.
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