Why perform an ACL augmentation?

Anterior cruciate ligament (ACL) reconstruction has evolved considerably over the past 30 years. This has largely been due to a better understanding of ACL anatomy and in particular a precise description of the femoral and tibial insertions of its two bundles. In the 1980s, the gold standard was anteromedial bundle reconstruction using the middle third of the patellar ligament. Insufficient control of rotational laxity led to the development of double bundle ACL reconstruction. This concept, combined with a growing interest in preservation of the ACL remnant, led in turn to selective reconstruction in partial tears, and more recently to biological reconstruction with ACL remnant conservation. Current ACL reconstruction techniques are not uniform, depending on precise analysis of the type of lesion and the aspect of the ACL remnant in the intercondylar notch.

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“…Surgically speaking, the interest in preserving the intact bundle is beneficial for several reasons, all described in the literature [54]:…”

Section: Partial Reconstructionsmentioning

confidence: 99%

The evolution of ACL reconstruction over the last fifty years

Chambat

Guier

Sonnery‐Cottet

et al. 2013

International Orthopaedics (SICOT)

209

162

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“…The proportion of isolated bundle tears in the knees undergoing ACL reconstruction was only 7% in this study, and an isolated PL bundle tear was detected in only one (0.6 %) of 156 knees. Surgical reconstruction might be required in symptomatic patients with partial ACL tears [13,21,33], and some surgeons prefer an ACL augmentation technique when treating the patients with partial ACL tears [4,5,33]. However, our study found that most remnant bundles are often loose and nonfunctional, even if the ACL remnant bridges the femur and the tibia [3].…”

Section: Discussionmentioning

confidence: 67%

How Useful Is MRI in Diagnosing Isolated Bundle ACL Injuries?

Chang

Choi

et al. 2013

Clinical Orthopaedics &Amp; Related Research

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Background Selective bundle anterior cruciate ligament (ACL) reconstruction and/or remnant ACL preservation may be reasonable options for some patients. However, the frequency of isolated anteromedial (AM) or posterolateral (PL) bundle injuries in patients undergoing ACL reconstruction is unknown, and the value of MRI for prediction of this injury pattern is likewise unknown. Questions/purposes We sought to determine (1) the proportion of knees with an intact AM or PL bundle in patients undergoing ACL reconstruction; (2) whether MRI predicted the bundle conditions seen at the time of surgery; and (3) whether the accuracy of the MRI prediction was affected by the timing of MRI after injury. Methods During primary ACL reconstructions of 156 knees, conditions of AM and PL bundles were separately examined and classified into three categories: (1) completely torn; (2) attenuated; and (3) intact. Then, the bundles were assessed by blinded observers on MRI and classified into the corresponding three categories for 77 patients who had an MRI at our institution using a standard protocol. Diagnostic accuracy of MRI was computed, and the early MRI group (B 6 weeks from injury to MRI acquisition) was compared with the late MRI group ([6 weeks). Results Only 11 (7%) of the 156 knees we treated had an intact AM (one knee) or PL bundle (10 knees). Another 55 knees (35%) had a structurally continuous but attenuated AM or PL bundle. The overall diagnostic accuracy of MRI was 83%; accuracy was better for the AM bundle than the PL bundle (91% versus 78%; p = 0.026). MR prediction was less accurate in the early MRI group, particularly for PL bundle injury.

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“…The definition of remnant-preserving ACLR surgery is controversial because it currently refers to the following three major procedures: selective bundle augmentation (SBA) ACLR in a partial lesion, involving either the posterolateral or anteromedial bundle with functional remaining fibers; augmentation (AG) ACLR in a partial lesion, involving one or both bundles with some remaining functional tissue; and ACLR in a complete lesion, involving both bundles with some remaining nonfunctional tissue (NFRP-nonfunctional remnant preservation) [51][52][53][54][55][56]57 Partial ACL tears are frequent (5 %-38 %) [62•], and the remnant fibers have been given more importance in recent years. ACLR using a remnant-preserving technique also called ACL augmentation supposedly improves the ligamentization process, since the remnant functional fibers may biomechanically protect the graft, the vascularized remnant synovial envelope may enhance vascularization, and the valve mechanism created by the remaining tissue and the tunnel may inhibit the entry of synovial fluid, resulting in less tunnel enlargement; also, histological studies have shown mechanoreceptors in the remaining tissue that may optimize proprioceptive function [52, 54, 55, 57••, 58, 59•, 62•, 63••, 64,65].…”

Section: Remnant-preserving Aclrmentioning

confidence: 99%

“…Regarding the three types of remnant-preserving ACL surgeries, SBA is believed to provide better knee stability results, followed by AG and, lastly, by NFRP [51][52][53][54][55][56]57 Tunnel enlargement is caused by high levels of cytokines and inflammatory agents in the postsurgery synovial fluid bathing the tunnel graft-bone interface and micro-motion in this environment; also, tunnel enlargement is more common in the tibia consequent to gravity. Although a correlation between tunnel enlargement and clinical outcomes has not been conclusively demonstrated, it remains a concern in revision surgery.…”

Section: Remnant-preserving Aclrmentioning

confidence: 99%

Updates in biological therapies for knee injuries: anterior cruciate ligament

Franciozi

Ingham

Gracitelli

et al. 2014

Curr Rev Musculoskelet Med

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There have been many advances in anterior cruciate ligament reconstruction (ACLR) techniques incorporating biological treatment. The aim of this review is to discuss the recent contributions that may enlighten our understanding of biological therapies for anterior cruciate ligament (ACL) injuries and improve management decisions involving these enhancement options. Three main biological procedures will be analyzed: bio-enhanced ACL repair, bio-enhanced ACLR scrutinized under the four basic principles of tissue engineering (scaffolds, cell sources, growth factors/cytokines including platelet-rich plasma, and mechanical stimuli), and remnant-preserving ACLR. There is controversial information regarding remnant-preserving ACLR, since different procedures are grouped under the same designation. A new definition for remnant-preserving ACLR surgery is proposed, dividing it into its three major procedures (selective bundle augmentation, augmentation, and nonfunctional remnant preservation); also, an ACL lesion pattern classification and a treatment algorithm, which will hopefully standardize these terms and procedures for future studies, are presented.

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Why perform an ACL augmentation?

Abstract: This study provides a detailed justification in preserving ACL remnants and their vital role in surgical reconstruction of partial anterior cruciate ligament tears.

Cited by 64 publications

References 38 publications

The evolution of ACL reconstruction over the last fifty years

The evolution of ACL reconstruction over the last fifty years

How Useful Is MRI in Diagnosing Isolated Bundle ACL Injuries?

Updates in biological therapies for knee injuries: anterior cruciate ligament

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