Background

Graft failure rates following anterior cruciate ligament (ACL) reconstruction remain problematic, particularly in young athletes returning to sport. Internal Bracing of the ACL graft with independently tensioned suture tape has been shown to increase the strength of the construct and anterolateral ligament (ALL) reconstruction has been associated with reduced ACL re-rupture rates.

Aim

This study primarily aimed to evaluate graft failure rates in patients undergoing ACL reconstruction with patellar tendon autograft reinforced with independently tensioned suture tape, plus ALL augmentation also with suture tape. Secondary aims included evaluating secondary surgery rates and patient-reported outcome measures (PROMs).

Methods

This prospective observational study included all patients who underwent primary ACL reconstruction with patellar tendon autograft, augmented with suture tape for both the ACL graft and ALL between 2018 and 2022 in a single surgeon’s practice. Patients were excluded if they had previous ACL reconstruction or concomitant multiligament injury requiring surgery. The addition of the ALL internal brace to the surgeon’s standard method of ACL reconstruction was based upon patient risk factors including age, sporting level and degree of laxity. Patients were followed up remotely at the time of the study to assess the incidence of graft failure, secondary surgery, and PROMs using KOOS, SANE score and Marx activity rating. Preoperative and 2-year PROMs were compared using Wilcoxon matched-pair test in SPSS. Tests of significance were set to a p-value <0.001 with a 95% confidence interval.

Results

Seventy patients met the inclusion criteria, with 7 (10%) lost to follow-up. Of the 63 patients analysed, the median age was 30.7 years (IQR = 23.5 - 45). Twenty-four patients were female (38%). The median pre-injury Marx activity score was 12 (IQR = 4 – 15.8). The mean follow-up duration was 3.4 ± 1 years, with the minimum follow-up 2 years. The overall graft failure rate was 1.6% (1 patient), occurring in a 21-year-old male with hypermobility syndrome who re-ruptured his ACL at 42 months postoperatively whilst playing semi-professional football.

Significant improvements were observed in all KOOS domains and SANE knee scores from preoperative to 2 years postoperative (p<0.001). There was no significant change in Median Marx activity score at 2 years (8, IQR = 3 – 12, p=0.046). The rate of subsequent operations was 16% (10 patients), primarily for meniscal or cartilage-related procedures. One patient (1.6%) underwent further surgery for hardware irritation.

Conclusion

ACL reconstruction using patellar tendon autograft reinforced with internal bracing and ALL augmentation demonstrates a low failure rate of 1.6% at a mean of 3.4 years postoperatively. This result is encouraging when compared to traditional ACL reconstruction techniques, where higher failure and revision rates have been reported. The PROMs results indicate that patients experienced satisfactory functional recovery. This technique is safe and well-tolerated, suggesting potential for routine clinical use to reduce graft failure rates in high-risk patients.