Dynamic Intraligamentary Stabilization (DIS) for treatment of acute anterior cruciate ligament ruptures: case series experience of the first three years

Abstract

BackgroundIn recent years, the scientific discussion has focused on new strategies to enable a torn anterior cruciate ligament (ACL) to heal into mechanically stable scar tissue. Dynamic intraligamentary stabilization (DIS) was first performed in a pilot study of 10 patients. The purpose of the current study was to evaluate whether DIS would lead to similarly sufficient stability and good clinical function in a larger case series.MethodsAcute ACL ruptures were treated by using an internal stabilizer, combined with anatomical repositioning of torn bundles and microfracturing to promote self-healing. Clinical assessment (Tegner, Lysholm, IKDC, and visual analogue scale [VAS] for patient satisfaction scores) and assessment of knee laxity was performed at 3, 6, 12, and 24 months. A one-sample design with a non-inferiority margin was chosen to compare the preoperative and postoperative IKDS and Lysholm scores.Results278 patients with a 6:4 male to female ratio were included. Average patient age was 31 years. Preoperative mean IKDC, Lysholm, and Tegner scores were 98.8, 99.3, and 5.1 points, respectively. The mean anteroposterior (AP) translation difference from the healthy contralateral knee was 4.7 mm preoperatively. After DIS treatment, the mean 12-month IKDC, Lysholm, and Tegner scores were 93.6, 96.2, and 4.9 points, respectively, and the mean AP translation difference was 2.3 mm. All these outcomes were significantly non-inferior to the preoperative or healthy contralateral values (p < 0.0001). Mean patient satisfaction was 8.8 (VAS 0–10). Eight ACL reruptures occurred and 3 patients reported insufficient subjective stability of the knee at the end of the study period.ConclusionsAnatomical repositioning, along with DIS and microfracturing, leads to clinically stable healing of the torn ACL in the large majority of patients. Most patients exhibited almost normal knee function, reported excellent satisfaction, and were able to return to their previous levels of sporting activity. Moreover, this strategy resulted in stable healing of all sutured menisci, which could lower the rate of osteoarthritic changes in future. The present findings support the discussion of a new paradigm in ACL treatment based on preservation and self-healing of the torn ligament.

Clinical Outcomes of Arthroscopic Primary Anterior Cruciate Ligament Repair: A Systematic Review from the Scientific Anterior Cruciate Ligament Network International Study Group

“…reported outcomes at medium-to long-term follow-up (range of mean follow-up 43.3-79 months) 41,48,49,52 including the mean IKDC subjective score (range 87.3-100), the mean Lysholm score (range 85.3-100), and the mean Tegner activity score (range 5-7). The remaining 10 studies 36,40,[42][43][44][45][46]50,51,53 reported the same outcome measures at short-term follow-up (range of mean follow up 12-38.4 months). At final follow-up, these studies reported a mean IKDC subjective score of 89.5-98, a mean Lysholm score of 93-100, and a mean Tegner activity score of 5-7.…”

“…The remaining 14 studies were Level IV cases series. [40][41][42][43][44][45][46][47][48][49][50][51][52][53] The flowchart for the search strategy is depicted in Figure 1.…”

“…A total of 1002 patients who underwent arthroscopic primary ACL repair formed the overall population evaluated in this systematic review. These patients underwent ACL repair with either suture anchor repair (SAR) (n ¼ 158), 37,39,42,46,48,49 dynamic intraligamentary stabilization with Ligamys (DIS Ligamys) (n ¼ 779), 35,36,40,41,43,44,[50][51][52][53] bridge-enhanced ACL repair technique (i.e., BEAR) (n ¼ 10), 38 suture pullout repair (n ¼ 13), 45 or augmented ACL repair using suture tape reinforcement with internal brace (IB) (Internal Brace Ligament Augmentation Repair; Arthrex, Naples, FL) 47 (n ¼ 42).…”

“…However, several series reported that no patients underwent a subsequent ACL reconstruction, at mean final follow-ups ranging between 31.3 and 72 months, but all of these studies comprised very small numbers of patients. 41,45,48 In contrast, in the noncomparative studies that evaluated DIS Ligamys, 7 studies 37,41,44,45,[51][52][53] reported a wide range of reintervention for hardware removal (1.8%-100%). The greatest rate was reported by Ateschrang et al 43 because their study eligibility criteria required that all included patients had undergone implant removal.…”

“…However, other authors also reported high rates of reoperation for removal including Kohl et al, 40 who reported a rate of 60%. Six 36,40,44,50,51,53 of the eight 36,40,42,44,[50][51][52][53] noncomparative studies evaluating DIS Ligamys reported clinically significant stiffness in 5.31% to 40% of their respective cohorts. The reoperation rate after DIS Ligamys for ACL reconstruction varied between 2.9% at 12 months 51 to 20% at 60 months.…”