Summary

The findings of this review demonstrate that ACL reconstruction with suture tape augmentation has a positive effect on all graft types in terms of strength and load capacity without limiting range of motion of the knee.

Abstract

Background

New techniques are being created to decrease the failure rate of ACL grafts and prevent revision surgery. One such technique involves high strength suture tape, also referred to as an InternalBrace™ (Arthrex Inc.). Recent literature has highlighted the overall use of suture tape for ACL reconstruction, but no study has compared suture tape augmentation between graft types. The purpose of this study was to perform a systematic review of the literature to determine the potential benefits of augmenting with an internal brace depending on type of graft (ie BPTB, quadriceps, hamstring).

Methods

A systematic literature search of MEDLINE (Ovid), Embase, Scopus, Web of Science Core Collection, clinicaltrials.gov, and the Cochrane Central Register of Controlled Trials (CENTER) was performed in March 2022 according to PRISMA guidelines to identify all articles related to suture tape augmentation of ACL grafts. Studies examining biomechanical properties and clinical patient outcomes with internal bracing were included. Studies including revision surgery, additional ligament injury, and ACL repair surgery were excluded.

Results

A total of 926 studies were identified, 10 of which met inclusion criteria. 5 studies used hamstring tendon (HT) (50%), 3 used quad tendon (QT) (10%), 1 used bone-patellar tendon-bone (BPTB) (10%), and 1 study used both HT and QT grafts (10%). Across multiple studies, HT grafts on porcine models showed a range of decreased dynamic and peak elongation (15-56%), increased load to failure (20-77%), and increased initial and final dynamic stiffness (31-47%) of suture tape augmented grafts compared to controls. Human studies found no significant difference in post-operative physical exam findings compared to control groups, with suture tape augmented grafts having significantly less laxity post-surgery compared to hamstring tendon alone (0.8 vs 1.9 mm). QT graft animal studies increased graft strength with normal graft incorporation and graft-to-bone healing at 6-month post-surgical histological assessment. Human studies showed positive outcomes with suture tape augmentation, with one study showing 9 out of 11 patients (82%) returning to pre-injury activity level. Another study found no difference in negative outcomes, along with higher KOOS scores reported in suture tape augmented patients compared to controls. The BPTB graft bone model study found decreased cyclic displacement by 31% (2.9 ± 0.8 mm) and increased load (758 ± 128 N) and stiffness (156 ± 23 N/mm) in the suture tape augmentation group compared to non-augmented groups.

Conclusion

HT, QT, and BPTB grafts augmented with suture tape demonstrate an effective method for ACL reconstruction. All graft types used with suture tape augmentation showed no evidence of clinical disadvantage, with some studies indicating significant biomechanical or clinical advantages compared to conventional ACL reconstruction. Notably, HT with suture tape augmentation reduced laxity, which was not seen in the use of QT. Further research is required to better understand the clinical application of suture tape augmentation for ACL reconstruction.