All-Inside Anterior Cruciate Ligament Reconstruction With Augmentation Using the Native Anterior Cruciate Ligament Remnant by Suture Approximation

Abstract

Anterior cruciate ligament (ACL) rupture remains a debilitating orthopaedic pathology with a substantial economic and psychological burden on patients, especially athletes. The purpose of ACL reconstruction is to attain maximum joint stability and functionality, allowing patients to resume their previous level of activity. Several graft options and techniques are available for ACL reconstruction. The all-inside remnant-preservation technique is a minimally invasive approach aiming for improved proprioception, better graft integration, and increased graft strength via ACL augmentation by suture approximation with an optimal anatomic reconstruction. ACL augmentation is associated with a decreased risk of rerupture. Moreover, enhancement of knee proprioception via the presented technique allows an early return to activity by patients because weight bearing (with a brace) can be initiated as early as day 1 postoperatively. Patients can resume running activities by 2 months postoperatively and return to pivot sports by 3 months postoperatively. Despite this surgical procedure being technically demanding, it is associated with improved clinical outcomes and functional capacities. Patients are also found to better tolerate the postoperative rehabilitation protocol.

All-Inside Arthroscopic Anterior Cruciate Ligament Reconstruction and Internal Brace With Recycling Suture

“…[3][4][5][6][7] In the previous literature, internal brace augmentation was performed by using FiberTape (Arthrex) to protect the ACL graft and could augment the graft with biologic tissue such as amnion, or bone marrow concentrate. [8][9][10]12,13 However, in a cadaveric study, Lai et al 14 showed that suture augmentation also improved the ultimate load to failure and cyclic displacement in ACL grafts. There was also a surgical technique using multiple suture strands to augment ACL which was reported by Kuptniratsaikul et al 15 The suture acts as a structural tie before fully ligamentization of the ACL.…”

“…In the previous literature, internal brace augmentation was performed by using FiberTape (Arthrex) to protect the ACL graft and could augment the graft with biologic tissue such as amnion, or bone marrow concentrate. 8 , 9 , 10 , 12 , 13 However, in a cadaveric study, Lai et al. 14 showed that suture augmentation also improved the ultimate load to failure and cyclic displacement in ACL grafts.…”

Remnant Tensioning Through Pullout Sutures From the Femoral Tunnel During Anatomic Anterior Cruciate Ligament Reconstruction

“…This concept has led to increased interest in studies of remnant preservation, proven by the recent surge in publications in the field of repair and remnant preservation. 2 , 3 , 6 , 7 , 8 , 12 Because of newer information about the remnant, ACL is now considered as an organ with neural and vascular tissues and not merely a stabilizing structure. 11 Many histologic studies have confirmed that remnants of torn ACL retain vascularized synovial sheets, numerous fibroblasts and myofibroblasts, and various mechanoreceptors.…”

“…Most of these techniques vary in femoral fixation methods. 7 Aperture fixation with interference screw on femoral side is a straightforward technique and found to have similar clinical or radiographic outcome compared with cortical suspensory button fixation. 9 In our technique, we pulled the sutures holding the remnant through the femoral tunnel along with the hamstring graft and fixed it with an interference screw.…”

“…5 Various techniques of remnant tensioning are described in the literature, but they are technically demanding and difficult to replicate. [6][7][8] Some of these techniques need separate fixation devices for the remnant, making those techniques costly and nonanatomical. 6 Some require a sizeable outside incision to secure remnant sutures, whereas some require tampering with a primary suspensory fixation device for graft.…”