A comparative review on ACL reconstruction vs internal brace augmentation

Received: 11-Aug-2022, Manuscript No. jotsrr-22-73047; Editor assigned: 12-Aug-2022, Pre QC No. jotsrr-22-73047(PQ); Accepted Date: Sep 07, 2022 ; Reviewed: 26-Aug-2022 QC No. jotsrr-22-73047 (Q); Revised: 03-Sep-2022, Manuscript No. jotsrr-22-73047(R); Published: 09-Sep-2022, DOI: 10.37532/1897- 2276.2022.17(8).72

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Abstract

Increasing knee injuries mainly of Anterior Crucial Ligament has led to development of different surgical procedures for its treatment. ACL reconstructive surgery is the most frequently used surgery in orthopaedic field. It is performed by either a Bone-Patellar Tendon-Bone (BPTB) or Semitendinosus and Gracilis Tendon (STG) graft. Earlier the ACL injury was treated by reconstructing the ligament but recurrence of 2nd injury after surgery was reported. This led to the development of a suture to tie up the graft in its place that provides more knee stability and good functional outcomes. The functional outcome of the surgeries was evaluated by some outcome measures like IKDC, KOOS, Lysholm score etc. The patients who underwent surgery were asked to perform some physical tests to evaluate the success rate of surgery. The results of these tests determined the motion, functional activity, efficacy in sports. This review focuses on understanding the benefits of suture augmentation in combination with ACL reconstruction andalso discusses the combination of these two modalities that has led to a revolutionary change in the future of the ACL ligament surgery

Keywords

ACLR, anterior cruciate ligament, grafts, knee injury

Introduction

One of the most frequent knee injuries in teen athletes is the fracture of ACL ligament [1, 2]. The most commonly damaged part of the knee is Anterior Cruciate Ligament (ACL), responsible for around 50% of all injuries to the knee ligament [3]. The injury is prevalent among the athletes, especially the females. Reasons attributed for gender-based observation include the difference in neuromuscular bluid and physique among the genders. Anatomical pattern of pelvis and legs have a hormonal influence of Oestrogen. During athletic events, the numbers of accidents arise. Soccer is one of the games that have the greatest ACL injury incidence [4, 5]. The individual’s response to cope-up with the injury varies when allowed to heal without any interventions. The partial nature of the injury may heal without intervention. However, it takes more than 90 day, and the symptoms may persist in many individuals. Severe injuries are the potential candidates for surgical management. The meniscus, when damaged, often demands more attention than any type of injury [6, 7].

With the incidence of tearing of the ACL and the constant need for enhanced reconstructive procedures, surgeons are continuously searching for future developments in surgical techniques. While some studies have shown strong results in ACL regeneration utilizing allograft tissue, there is a high risk of surgical failure in younger athletes].Besides, the risk of additional surgical site often prevails with autograft. The identification and rectification of this complication will be a potential therapeutic approach to enhance the reconstructive procedure for the management of used in ACL injury [8- 10].

Literature Review

STRUCTURE OF ACL

The ACL is the knee's main static stabiliser against tibiato-femur anterior translation. The ACL is a circle-shaped ligament that derives from the medial portion of the lateral femoral condyle and extends posteriorly through the intercondylar notch. The attachment's anterior surface is nearly vertical, while the posterior part is convex. In the direction of the tibia, the ligament runs distally,anteriorly, and medially. The ligament's strands move slightly to the exterior throughout the duration of its existence. The ligament averages 38 mm in length and 11 mm in width on average [11].

ACL RECONSTRUCTION

The most important surgical procedure performed in orthopaedic field is the reconstruction of Anterior Crucial Ligament (ACL). Once torn, the fan-shaped complex ACL lack the ability to repair or regenerate by itself. With rising life expectancy and quality of life changes in developed nations, athletic standard and demand are increasing among the older aged patients [12, 13]. Injured athletes forced to compete the professional game event are typically recommended for reconstructive operation. The ideal choices of graft may include BPTB & STG. Many competitors suffering from injured ACL fail to recover back to their degree of pre-injury activities successfully and one of the biggest explanations for this may be because athletes may not recover to their complete potential [14-17].

SUTURE AUGMENTATION

In order to speed up postoperative healing, SA has been employed to establish fast stabilisation before the graft integration. With aims close to ACLR, this procedure has been utilised for postero-medial corner and medial collateral ligament reconstructions and repairs, Achilles tendon repairs posterior cruciate ligament avulsion fracture repairs, elbow ulnar collateral ligament repairs, and lateral ankle weakness reconstructions [18].

DRAWBACKS OF ACLR

While ACL reconstructions have a high progress rate, they also have a high failure rate which may contribute to chronic damage following procedure. ACL replacement patients are unlikely to do as well as they did previous to operation. Following treatment, the early results of ACLR showed gradual degradation. These effects were linked to comprehensive soft tissue deconstruction and cast immobilisation, which resulted in a high rate of discomfort, rigidity, and dysfunction. Although ACL reconstruction improves anterior-posterior knee flexibility, there is a reduction in knee strength and work done by the muscles around the damaged knee post operatively, indicating that donor site morbidity contributes to the changed knee kinematics found after ACL injury, according to Kowalk et al. The number of researches focused onexamining gait and knee kinematics after ACL reconstruction indicate an increase in gait pattern relative to pre-surgery, but compensatory muscle usage mechanisms continue in the number of people, suggesting sub-optimal graft results.Measures used for outcomes of ACL reconstruction knee-specific success tests are widely used as an assessment during knee surgery, especially during anterior cruciate ligament reconstruction surgery [19].

ANTERIOR-POSTERIOR KNEE LAXITY

On both knees, anterior-posterior laxity values were calculated by a certified physical therapist with the KT-1000 Knee Arthrometer.Three manual limit measurements were carried out and averaged the displacement readings. The gap between legs was measured and used for the study (surgical knee-contralateral intact knee). Knee injury and Osteoarthritis Outcome Score For the analysis of patient-reported performance, the KOOS is applied. The KOOS assesses 5 domains: quality of life linked to the knee (QOL), role of sports and exercise, everyday living tasks, symptoms, and discomfort. On a scale varying from 0 to 100, the sub scores were presented, with 100 showing a perfect knee. [20,21].

ACL RETURN TO SPORT AFTER INJURY (ACLRSI) SCALE

This scale is used for the evaluation of the patient’s ability to return back to its normal functional activities. it is an effective questionnaire which is comprised of 12 questions that include unique features, like management of risk and trust of patient, and is related to the preparation of an athlete to get back to its functional activity.The rating of this scale varies from 0 to 100, reflecting the status of patients who can return to their sports after assessing their score. Score of 56 or less on ACL RSI scale has accurately defined the status of older patients who, because of psychological reasons, can struggle to get back to their sport after their surgical procedure [22].

INTERNATIONAL KNEE DOCUMENTATION COMMITTEE (IKDC)

An IKDC questionnaire is a quantitative scale that assesses the overall functional activity of the patient by providing scores according to the question category. The questionnaire is meant to include three categories: complaints, involvement in activities and knee activity. Problems such as pain, fatigue, swelling and knee giving-way appear to be assessed by the subscale of symptoms. Lysholm score it is a scale that provides 100 points rating for the evaluation of patient’s knee-specific problems, including mechanical locking,pain, discomfort, inflammation, stair climbing, knee instability and squatting, is the Lysholm score (Table 1).

Table 1. Elements and its scores

Currently, the Lysholm Scale includes eight elements that are scored as given below: On an increasing scale, any query answer has been given an arbitrary ranking. The number of each answer to the eight questions is the overall score, which can vary from 0-100. Higher scores reflect a stronger performance and less signs or disorders. ACLR surgical technique using suture tape [23].

Graft preparation an anterior dissection is used to extract a normal bone patellar tendon bone autograft using 20 mm–25 mm bone plugs for autografts. Achilles' allograft with bone block is another choice for allograft. After that, a 2 mm hole is drilled into the superior plug to scale and ready the graft (and inferior bone plugs for autograft). Suture tape is then wrapped across the distal end of the femoral bone block and threaded through the graft with a loose needle to the intended anterior side.

Graft passage a normal femoral tunnel is created across the anterior medial portal, and the tibia is drilled antegradely. The graft is then threaded into the tibial tube and fixed in the femur with an intrusion pin. The anterior medial portal's suture tape augmentation tails (initially labelled) are then recovered. After that, the graft is cycled, and the isometric point is verified. For the posterior drawer, the leg is almost completely extended. Suture Tape Augmentation Fixation-Crucially, during the graft, the FiberTape internal brace is clamped individually. After the allograft ACL has been placed on the tibia and fibula, focus is shifted to the internal brace's final fixing. At this point, the knee can be tested to confirm that it has a complete scope of movement

After the patient has shown a possibly the optimally functioning quadriceps muscle and strong leg coordination, range of movement is established using a CPM simulator, and weight-bearing is advanced as acceptable. Closed-chain strengthening is stressed, and patients are normally permitted to return to sports 6 months to 9 months following surgery.

BENEFIT OF ACLR OVER SA

Due to the additional mechanical intensity, it may offer in the initial recovery and healing period, SA is presently being employed to assist ACLR. The internal brace has the added benefit of strengthening the overall build, which protects the graft during the remodelling and revascularization phase.

Strong associations among SA and better periods of recovering from preinjury activity level and percentage of preinjury activity level were found by Bodendorf et al. [24], with a tendency toward an enhanced frequency of returning to preinjury activity level in table 2.

Table 2. Comparative pre- and post-patient related outcomes

The comparative results pre- and post-surgery are addressed. The findings revealed that there was no substantial difference in pre-operative scores among the SA and normal ACLR categories. SA had slightly higher IKDC and KOOS ratings after surgery. SA had higher comparative KOOS, ADL, and pain sub ratings, but this disparity still trended toward relevance. This showed that participants in the SA community returned to pre-injury activity levels much faster than those in the traditional ACLR group.

Biomechanical experiments utilising SA to test ACLR have shown positive results. Cook et al. used a canine model to evaluate their theory [25]. Six months after treatment, the findings of a quadriceps tendon allograft with SA showed no major variations in force at fixed displacement sites or rigidity relative to the original ACL. In this study, the SA showed consistent healing and no signs of osteophyte, cartilage or meniscal abnormalities. As opposed to graft alone, a biomechanical analysis conducted by Bachmaier et al. of bovine ACLRs supplemented by suture tape showed dramatically reduced graft dynamic elongation during load applied and enhanced failure load.This impact was observed to be particularly powerful with grafts of limited diameter. This research also discovered that the suture tape's loadsharing role would not take control until the graft had significantly elongated, implying that the suture augment will not protect the graft from loads of low tension. These findings indicate that the SA would offer improved dynamic stabilization, particularly soon in the healing phase of the fragile graft, that may be beneficial to the recovered ACLR before the graft is secure [26] (Figure 1).  Depicting the surgical procedure of ACLR with SA On three paediatric patients, Smith et al. effectively implemented temporary usage of SA for ACL repair [27]. Short-term clinical progress has been shown by DiFelice et al. utilising a SA construct to offer support for primary ACL repairs [28]. Interestingly, Peterson et al. observed no long-term substantial variations in return to operation or KOOS ratings between the augmented and nonaugmented ACL groups utilising a common conceptual approach.

Figure 1: Depicting the surgical procedure of ACLR with SA

LIMITATIONS OF ACLR WITH SA

The primary disadvantage regarding use of an internal brace would be the risk of over constraining the joint and leading to loss of motion if the internal brace is too tight. For this reason, the internal brace is fixated separately from the graft and always at full hyperextension. Another concern would be potential stress shielding of the graft itself, but this also can be avoided by placing a haemostat tip underneath the FiberTape at the time of tibial fixation to build in a bit of slack with the internal brace. This ensures that the graft sees load, which is important in the tissue revascularization and remodelling process.

Conclusion

ACL tears can be distressing. However, the right surgical procedure can get patients walking again. In most cases, ACL reconstruction has long-term benefits. However, there may be some cases where ACL reconstruction along with suture augmentation will be successful, with shorter recovery. Both the techniques have their own advantages and disadvantages. Both have equal success and failure rates. The failure rate of ACL reconstruction earlier has led to the development of SA combined with ACLR which provide more patient compliance and better player performance.

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