Reduced Incidence of Revision Anterior Cruciate Ligament Reconstruction With Internal Brace Augmentation

Abstract

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.

Keywords: anterior cruciate ligament; anterior cruciate ligament reconstruction; internal bracing; suture tape augmentation.

Figure 1.

Flowchart of included and excluded patients and the matching process. ACLR, anterior cruciate ligament reconstruction; IB, internal brace.

Figure 2.

An intraoperative photograph of an all–soft tissue quadriceps tendon autograft prepared for both proximal and distal suspensory fixation with additional independent internal brace augmentation. The pull suture (white arrow) is used to pass the femoral cortical button (black arrowhead) through the femoral socket. The femoral shortening strands (black arrow) are used for docking the graft into the socket and retensioning the graft proximally to achieve final graft fixation. The internal brace is passed through 2 holes on the femoral button where it then runs parallel to the graft (asterisks). A nitinol wire (not pictured) is used to pass the internal brace under 1 suture on the graft both proximally and distally on both sides (white arrowheads).

Figure 3.

Intraoperative arthroscopic views of a right knee from the anterolateral portal of 2 quadriceps tendon autografts at 60° of flexion with internal brace augmentation (asterisk).

Figure 4.

Kaplan-Meier survival curve for the available time frame. Censored data are denoted by a plus (+) symbol.