No Difference in Clinical Outcomes Between Concomitant Anterior and Posterior Cruciate Ligament Reconstruction With and Without Independent Suture Tape Augmentation

Purpose

To compare clinical and functional outcomes (including range of motion, clinical laxity, reoperation/revision rates, and patient-reported outcome measures) of combined anterior cruciate ligament/posterior cruciate ligament reconstruction (ACLR/PCLR) with and without suture tape (ST) augmentation via a propensity-matched cohort analysis.

Methods

A retrospective review was performed to identify all patients who underwent simultaneous primary ACLR/PCLR between 2001 and 2022. A 1:1 propensity match was performed using patient sex, Schenck classification grade, age ±8 years, and body mass index ±10 to produce 2 cohorts: ACLR/PCLR with and without (control) ST augmentation. Clinical outcomes (visual analog scale [VAS], range of motion, Tegner activity scale, Lysholm score, and International Knee Documentation Committee subjective score) were analyzed.

Results

The propensity match produced a final cohort of 50 ACLR/PCLR patients: 25 with ST augmentation and 25 nonaugmented controls. Most patients had a KD3M injury (12 in each cohort), and no significant differences were noted in concomitant neurovascular, meniscal, or chondral injuries between the groups. Forty patients (80%) completed follow-up at a mean of 4.7 years for the ST cohort and 8.5 years for the control cohort ( P >.05). Postoperative ST versus control values for outcome measures including VAS at rest (0.9 vs 1.5; P =.71), VAS with use (3.0 vs 2.2; P =.24), International Knee Documentation Committee (75.7 vs 76.3; P =.37), Lysholm (81.8 vs 77.6; P =.91), and Tegner activity (4.8 vs 5.4; P =.37) scores showed no differences ( P >.05 for all). There were no differences in excessive postoperative clinical laxity between ST and control cohorts (ST n = 1 vs control n = 2, Lachman 2+, P =.140; ST n = 3 vs control n = 1, posterior drawer 2+, P =.122). The total number of patients who underwent reoperation was 7 of 25 (28%) for the ST cohort and 8 of 25 (32%) for the control cohort ( P =.76).

Conclusions

Concomitant ACLR/PCLR utilizing ST augmentation showed similarly satisfactory postoperative clinical outcomes at a minimum 2-year follow-up compared to a matched cohort without ST. The use of an independent ST did not limit motion or increase the incidence of complications or revision surgery.

Level of Evidence

Level III, retrospective comparative case series.

Managing multiligament knee injuries (MLKIs) can prove extremely challenging for orthopaedic surgeons despite major technological advances and modern surgical techniques. Prior investigations have shown improved clinical and functional outcomes with surgical intervention compared to nonoperative treatment of MLKIs. ^, However, relatively high rates of perioperative complications, including arthrofibrosis, residual laxity, graft failure, and the need for revision surgery, have been reported. ^,^,

Suture tape (ST) augmentation is a form of intra-articular stabilization that is designed to provide additional biomechanical strength and support that acts as a checkrein if the reconstructed graft experiences supraphysiologic load, thus reducing the risk of plastic deformity and rerupture. ^, Biomechanical investigations have demonstrated that ST augmentation can increase ultimate tensile strength and reduce graft elongation after posterior cruciate ligament (PCL) reconstruction (PCLR), as well as significantly increase graft stiffness and load to failure after anterior cruciate ligament (ACL) reconstruction (ACLR). ^,^, Early clinical results of isolated ACLR or PCLR with ST augmentation have shown promise, with low rates of graft failure, complications, and reoperations, as well as a faster time to return to preoperative activity levels and improved patient-reported outcome measures (PROMs) at 2 years. ^, Additionally, some early clinical evidence suggests that ST augmentation in the setting of combined ACL/PCL injuries and multiligament knee reconstruction can provide successful patient outcomes with failure and complication rates equivalent to traditional reconstruction techniques. ^, However, there remains a paucity of literature specifically regarding the postoperative outcomes following combined ACLR/PCLR with ST augmentation.

The purpose of this study was to compare clinical and functional outcomes (including range of motion, clinical laxity, reoperation/revision rates, and PROMs) of combined ACLR/PCLR with and without ST augmentation via a propensity-matched cohort analysis. We hypothesized that ACLR/PCLR with ST augmentation would produce similar outcomes compared to nonaugmented ACLR/PCLR and would have no impact on perioperative complications or reoperation rates.

Methods

Following institutional review board approval (IRB: 07-004018), a retrospective review of a prospectively collected clinical database from a single institution was conducted to identify all patients who underwent simultaneous primary ACLR/PCLR between 2001 and 2022. Inclusion criteria consisted of patients who underwent primary concomitant ACLR/PCLR with or without independent ST reinforcement. Patients were excluded if they underwent revision ACLR/PCLR, were polytraumatized patients, had isolated ST application to either the ACL or PCL, or were deceased at follow-up. Patients who underwent a total knee arthroplasty (TKA) prior to final follow-up were included for all analyses except comparisons of final PROM scores.

All patients meeting initial inclusion and exclusion criteria were divided into 2 groups: (1) ACLR/PCLR with suture tape augmentation (ST group) and (2) nonaugmented ACLR/PCLR (control group). Patients in the ST cohort were matched 1:1 with patients in the control group of primary ACLR/PCLR without ST reinforcement. Matching was performed according to age at time of ACLR/PCLR (within 8 years), sex, body mass index (BMI; within 10 kg/m ²), and exact KD grade (according to the Schenck classification of knee dislocations). These matching criteria were chosen to facilitate direct comparisons of patients with the same knee injuries (exact KD grade) while also sharing similar demographic factors in accordance with prior studies evaluating cruciate reconstruction with suture tape augmentation. ^,

Patient medical records were individually reviewed to obtain patient demographics, preoperative and postoperative physical examination findings, concomitant procedures, reoperations, and complications. All patients were followed up clinically up to 2 postoperative years with an examination and radiographs per standard practice at our institution. Physical examinations were performed by the operating surgeon using a goniometer for range of motion. Patients beyond 2 postoperative years were contacted for follow-up via telephone or e-mail, when necessary, to collect postoperative PROM scores. Postoperative PROMs (including the visual analog scale [VAS], Tegner activity score, Lysholm score, and International Knee Documentation Committee [IKDC] subjective score) were obtained. ^,

Surgical Technique

The authors’ preference for ACLR with ST augmentation utilizes an all-inside technique with quadrupled semitendinosus-gracilis autograft, or 4-stranded allograft. The grafts were prepared with the GraftLink (Arthrex) technique incorporating an adjustable loop device (ALD) (TightRope; Arthrex) for suspensory fixation on both the femur and tibia. A suture tape (FiberTape; Arthrex) was passed through the femoral ALD’s cortical button and incorporated into the construct. The ACL femoral sockets were drilled antegrade via a low anteromedial portal to a minimum intraosseous depth of approximately 20 to 25 mm. A FlipCutter (Arthrex) was utilized to drill the tibia socket retrograde with a minimum intraosseous depth of approximately 30 mm. The graft was first passed into the knee joint and secured to the femur using the femoral ALD’s button against the cortex of the lateral femur. The tibial ALD was then passed into the knee joint and through the tibial socket using a passing suture. The external Attachable Button System (ABS; Arthrex) was utilized to pass the graft suspensory sutures and suture tape through the button and obtain fixation on the tibia. The graft was preliminarily cycled through flexion and extension to remove any potential creep. Prior to final graft tensioning, the suture tape was fixed distally with a suture anchor (SwiveLock; Arthrex) on the anteromedial tibial cortex approximately 1 cm distal to the tunnel in full extension. Final retensioning of the graft was then performed on both the femoral and tibial ALDs with the knee in full extension.

For PCLR and ST augmentation, the authors’ preference is an all-inside technique with either a quadrupled peroneus longus or tibialis anterior allograft ( Fig 1 ). The PCL GraftLink (Arthrex) technique was used to create a double suspensory fixation construct using ALD fixation on both the femur and tibia. The independent suture tape was passed through the femoral ALD’s cortical button to incorporate it into the construct. An accessory posteromedial portal and a 70° arthroscope were utilized to optimize arthroscopic visualization. The Anatomic Contour PCL Tibial Guide (Arthrex) was inserted and positioned at the base of the PCL facet between the mammillary bodies. A FlipCutter was used to drill a 40-mm tibial socket in retrograde fashion. On the femur, the native PCL anterolateral bundle footprint was identified, an accessory inferolateral portal was established, and a low-profile cannulated reamer was used to drill a 25- to 30-mm femoral socket. The tibial end of the PCL graft was inserted into the joint first using passing sutures, followed by the femoral end. The femoral ALD’s cortical button was flipped against the medial femoral cortex, and the graft was advanced into the femoral socket. The external ABS was attached to the tibial ALD and suture tape. The graft was appropriately tensioned in 90° of knee flexion, and the TightRope strands were tied over the ABS button and secured into a swivel lock anchor for backup fixation. The suture tape was fixed to the tibia via an additional swivel lock anchor in 90° of knee flexion. Afterward, final PCL graft tensioning was performed. Note that the authors performed tensioning and fixation of the PCL graft as described prior to final tensioning and fixation of the ACL graft. However, the femoral ALD cortical buttons on both the ACL and PCL grafts allowed for retensioning if needed, as determined by the operating surgeon. Final ACL/PCL constructs can be visualized in Figure 2 .

Image, AltText currently not available — Fig 1

Statistical Analysis

Data were collected and stored utilizing Excel (Microsoft) and REDCap (REDCap Consortium) software. Data were analyzed using BlueSky Statistics (BlueSky) and Prism GraphPad (GraphPad Software). Baseline patient characteristics were presented as means and percentages, with standard error of mean or 95% confidence intervals when appropriate. Physical examination findings and PROMs were analyzed for parametric/nonparametric assumptions utilizing Shapiro-Wilk normality tests. Continuous variables were then analyzed using Student t tests or Wilcoxon rank-sum tests. Categorical variables were analyzed using χ ² analysis or Fisher exact tests when appropriate. Statistical significance was defined as P <.05.

Results

A total of 137 patients underwent ACLR/PCLR with or without suture tape reinforcement between 2001 and 2022 at a single institution. Of these patients, 21 were excluded (12 revision ACLR or PCLR cases, 1 polytraumatized, 3 ST applied to only 1 ligament, 1 osteosarcoma, and 4 deceased at final follow-up). As a result, 116 patients (27 ST and 89 control) were eligible for a 2-year follow-up and able to participate in the propensity match. Twenty-five patients in the ST cohort were matched to a cohort of 25 control patients (ACLR/PCLR without ST) in a 1:1 fashion ( Fig 3 ).

Demographic patient characteristics are summarized in Table 1 . The average age for the ST cohort was 28.9 ± 12.5 years, while the average age for the control cohort was 29.8 ± 12.0 years. There were 18 men (72%) included in each cohort. The average BMI for the ST cohort was 30.4 ± 7.0, while the average BMI for the control cohort was 30.7 ± 6.5. There were no significant differences between the 2 groups regarding age, sex, and BMI, as well as no differences seen in concomitant neurovascular, meniscal, or chondral injuries. There were also no differences between the 2 cohorts with regard to the graft type (autograft vs allograft) ( P =.490).

Table 1

Demographics

Characteristic	Suture Tape (n = 25)	Control (n = 25)	P Value
Age, y	28.9 ± 12.5	29.8 ± 12.0	.754
Sex
Male	18 (72)	18 (72)	>.999
Female	7 (28)	7 (28)
BMI	30.4 ± 7.0	30.7 ± 6.5	.844
>35	7 (28)	6 (24)	.747
Smoking status	7 (28)	7 (28)	>.999
Graft type			.490
Autograft	2 (8)	0 (0)
Allograft	23 (92)	25 (100)
KD grade			>.999
KD2	2 (8)	2 (8)
KD3M	12 (48)	12 (48)
KD3L	9 (36)	9 (36)
KD4	1 (4)	1 (4)
KD5	1 (4)	1 (4)
Concomitant injuries
Concomitant meniscal injury	8 (32)	11 (44)	.382
Concomitant vascular injury	3 (12)	6 (24)	.269
Concomitant neurologic injury	8 (32)	5 (20)	.333
Concomitant cartilage injury	4 (16)	3 (12)	.684

NOTE. Data are expressed as mean ± standard deviation or n (%).

BMI, body mass index; KD, Schenck classification grade.

Physical examination findings and KD grading are summarized in Table 2 . The mean preoperative extension for the ST cohort was–0.2° ± 2.5°, while the mean preoperative flexion was 115.4° ± 22.0°. For the control cohort, the mean preoperative extension was 0.2° ± 6.6°, and the mean preoperative flexion was 113.9° ± 20.9°. There were no differences seen between the 2 groups for pre- and postoperative range of motion or clinical laxity ( P >.05). Mean range-of-motion arc at final clinical follow-up was 125.2° in the ST cohort and 120.1° in the control cohort ( P =.71). The mean postoperative extension for the ST cohort was–1.0° ± 2.1°, while the mean postoperative flexion was 124.2° ± 11.1°. For the control cohort, the mean postoperative extension was–0.3° ± 2.4°, and the mean postoperative flexion was 119.7° ± 19.6°. The mean postoperative Lachman and posterior drawer examinations were comparable between the groups at final follow-up ( P =.140 and P =.122, respectively). No patient had a grade 3 Lachman on final follow-up in either cohort, and 1 patient in the control cohort had a grade 3 posterior drawer on final follow-up.

Table 2

Physical Examination Findings and Schenck Classification (KD) Grade

Characteristic	Suture Tape (n = 25)	Control (n = 25)	P Value
Preoperative
Extension	–0.2 ± 2.5	0.2 ± 6.6	.333
Flexion	115.4 ± 22.0	113.9 ± 20.9	.746
Range of motion, °	115.6 ± 23.6 (106.3-124.9)	108.5 ± 35.5 (94.7-122.3)	.571
Lachman			.505
2+	19 (76)	17 (68)
3+	5 (20)	7 (28)
Not reported	1 (4)	1 (4)
Posterior drawer			.312
2+	12 (48)	9 (36)
3+	11 (44)	15 (60)
Not reported	2 (8)	1 (4)
KD grade			>.999
KD2	2 (8)	2 (8)
KD3M	12 (48)	12 (48)
KD3L	9 (36)	9 (36)
KD4	1 (4)	1 (4)
KD5	1 (4)	1 (4)
Postoperative
Extension	–1.0 ± 2.1	–0.3 ± 2.4	.247
Flexion	124.2 ± 11.1	119.7 ± 19.6	.844
Range of motion, °	125.2 ± 12.0 (120.5-129.9)	120.1 ± 21.5 (111.7-128.5)	.706
Lachman			.140
Negative	22 (88)	16 (64)
1+	1 (4)	5 (20)
2+	1 (4)	2 (8)
Not reported	1 (4)	2 (8)
Posterior drawer			.122
Negative	13 (52)	17 (68)
1+	8 (32)	4 (16)
2+	3 (12)	0 (0)
3+	0 (0)	1 (4)
Not reported	1 (4)	3 (12)