Analysis of Graft Types Augmented With an Internal Brace for ACL Reconstruction: A Systematic Review

Abstract

Background: New techniques are being developed to decrease the failure rate of anterior cruciate ligament (ACL) grafts and prevent revision surgery. One such technique involves high-strength suture tape (ST), also referred to as internal bracing. Recent literature has highlighted the use of ST for ACL reconstruction, but no study has compared ST augmentation between graft types. Purpose: To compare the use of ST augmentation for ACL reconstruction based on the type of graft used (ie, bone–patellar tendon–bone [BPTB], quadriceps, hamstring). Study Design: Systematic review; Level of evidence, 5. Methods: An online search of multiple databases was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and was completed April 2022 to identify studies related to ST augmentation of ACL grafts. Results: Of 926 studies identified, 10 met inclusion criteria. Five studies (50%) used hamstring tendon (HT), 3 (30%) used quadriceps tendon (QT), 1 (10%) used BPTB, and 1 (10%) used both HT and QT grafts. HT autografts augmented with ST had decreased dynamic and peak elongation (15%-56%), increased load to failure, and increased initial and final dynamic stiffness compared with controls. There was no significant difference in postoperative physical examination findings (range of motion, Lachman, pivot shift), except that ST-augmented grafts had significantly less laxity after surgery compared with HT alone (0.8 vs 1.9 mm; P < .05). QT allografts with ST augmentation showed increased graft strength. Human QT autograft studies showed higher Knee injury and Osteoarthritis Outcome Score scores compared with controls. BPTB allografts with ST augmentation had decreased cyclic displacement by 31% ( P = .015) and increased load (758 ± 128 N; P < .001) and stiffness (156 ± 23 N/mm; P = .003) compared with nonaugmented groups. The complication rate was low or showed no increase in the ST augmentation groups compared with control groups. Conclusion: HT, QT, and BPTB grafts augmented with ST demonstrate an effective method for ACL reconstruction. All graft types with ST augmentation showed no evidence of clinical disadvantage, with some studies indicating significant biomechanical or clinical advantages compared with conventional ACL reconstruction.

Advancements in Anterior Cruciate Ligament Repair—Current State of the Art

“…Augmentation techniques have emerged as a procedure for enhancing ACL reconstruction success [1,14,18]; they were applied both in ACL-R [46][47][48] and ACL repair [1,14,18,19]. In the ACL repair setting, they follow the same principles and indications as in ACL-R [46,47].…”

“…The two most notable augmentation strategies were suture-tape augmentation [47] and laterally based procedures, either LET or ALL-R [46,49].…”

“…The suture-tape augmentation concept, as described by the InternalBrace™ technique integrating FiberTape ® sutures within the TightRope implant for ACL repair, has revolutionized the landscape of ACL repair, offering a novel adjunctive technique to enhance the biomechanical properties of ligament reconstruction [44,45]. Augmenting the repaired ligament with a high-strength suture tape serves as a reinforcement mechanism, providing additional support and stability during the critical phases of healing and rehabilitation [1,18,47,51].…”

“…Moreover, the benefits of suture-tape augmentation extend beyond mere structural reinforcement. Studies have suggested that suture-tape augmentation may accelerate healing, reduce postoperative laxity, and enhance proprioceptive feedback, optimizing functional outcomes and facilitating an early return to activity [1,18,47].…”

“…With ACL repair, there is no need for graft harvesting, minimizing donor site morbidity and preserving the ligament's natural proprioceptive properties. Additionally, failed ACL repair can be converted to ACL reconstruction without compromising outcomes, providing a safety net for patients requiring further intervention [11,14,22,47,48].…”