Can A Surgically Repaired Acl Be Better Than Before

J Exp Orthop. 2022 Dec; five: 20.

Anterior cruciate ligament repair – past, present and future

Piyush Mahapatra

Trauma and Orthopaedic Section, Croydon University Hospital, 530 London Route, London, CR7 7YE United kingdom of great britain and northern ireland

Saman Horriat

Trauma and Orthopaedic Department, Croydon University Infirmary, 530 London Route, London, CR7 7YE UK

Bobby S. Anand

Trauma and Orthopaedic Department, Croydon Academy Hospital, 530 London Road, London, CR7 7YE Great britain

Received 2022 Mar 28; Accustomed 2022 May 31.

Data Availability Statement

All studies used to formulate this article are freely available online and readily searchable through PubMed (MEDLINE), EMBASE and Cochrane Library databases. A total listing of references is included within the manuscript.

Abstract

Background

This commodity provides a detailed narrative review on the history and current concepts surrounding ligamentous repair techniques in athletic patients. In item, we volition focus on the anterior cruciate ligament (ACL) as a case study in ligament injury and ligamentous repair techniques. PubMed (MEDLINE), EMBASE and Cochrane Library databases for papers relating to master anterior cruciate ligament reconstruction were searched past all participating authors. All relevant historical papers were included for analysis. Additional searches of the same databases were fabricated for papers relating to biological enhancement of ligament healing.

Current standard

The poor capacity of the ACL to heal is one of the main reasons why the current gold standard surgical treatment for an ACL injury in an able-bodied patient is ACL reconstruction with autograft from either the hamstrings or patella tendon. It is hypothesised that by preserving and repairing native tissues and negating the need for autograft that primary ACL repair may correspond a key footstep change in the treatment of ACL injuries.

History of primary ACL repair

The history of chief ACL repair volition be discussed and the circumstances that led to the near-abandonment of primary ACL repair techniques will be reviewed.

New primary repair techniques

At that place has been a recent resurgence in interest with regards to chief ACL repair. Improvements in imaging now allow for identification of tear location, with femoral-sided injuries, beingness more suitable for repair. We volition hash out in details strategies for improving the mechanical and biological environment in order to allow primary healing to occur.

In particular, nosotros volition explicate mechanical supplementation such as Internal Brace Ligament Augmentation and Dynamic Intraligamentary Stabilisation techniques. These are novel techniques that aim to protect the primary repair past providing a stabilising construct that connects the femur and the tibia, thus bridging the repair.

Bio enhanced repair

In add-on, biological supplementation is being investigated as an adjunct and nosotros will review the current literature with regards to bio-enhancement in the form platelet rich plasma, bio-scaffolds and stem cells. On the basis of current bear witness, there appears to be a role for bio-enhancement, however, this is not notwithstanding translated into clinical practice.

Conclusions

Several promising avenues of further inquiry at present exist in the class of mechanical and biological augmentation techniques. Further work is clearly needed only there is renewed involvement and focus for primary ACL repair that may yet show the new borderland in ligament repair.

Keywords: Inductive, Cruciate, Ligament, Principal, Repair, Reconstruction, Athletes

Review

Ligamentous injury in the athlete is a major cause of morbidity and fourth dimension away from sport (Waldén et al. 2001, 2022; Brophy et al. 2022; Lundblad et al. 2022). Ligamentous repair remains an ongoing aspiration in the treatment of athletic patients in order to try and facilitate a rapid and complete return to high level sporting activity.

The vast majority of ligamentous sporting injuries in athletes affects either the ankle or the knee (Darrow et al. 2009; Kerr et al. 2022; Rechel et al. 2022; Swenson et al. 2022). Although, the talocrural joint is more frequently injured than the knee, genu injuries are the leading cause of sport-related surgery (Joseph et al. 2022) and human knee ligament injuries can have devastating consequences on the sporting career of athletes. In particular, we will focus on the anterior cruciate ligament (ACL) as a case report in ligament injury and ligamentous repair techniques. PubMed (MEDLINE), EMBASE and Cochrane Library databases for papers relating to chief inductive cruciate ligament reconstruction were searched past each author. All relevant historical papers were included for analysis. Additional searches of the same databases were fabricated for papers relating to biological enhancement of ligament healing.

Nosotros will describe 'main repair' as any surgical procedure that involves restoring the original native injured ligament. If the procedure involves introducing a graft to replace the original injured ligament nosotros volition refer to this as a reconstruction. It is important for the reader to be clear of the differences every bit 'repair' is frequently used incorrectly within the literature to describe reconstruction techniques.

Anterior cruciate ligament injuries

Inductive cruciate ligament injuries account for anywhere between 25 and 50% of ligamentous knee injuries (Risberg et al. 2004) and pose unique clinic issues because of its poor chapters to undergo biological healing due to the local intra-articular conditions. A potential theory to explain this is that the synovial fluid and intra-articular movement prevents formation of a stable fibrin-platelet scaffold (Murray 2022). Without this scaffold, no chief healing tin can have place (Murray et al. 2000).

This poor chapters of the ACL to heal is ane of the principal reasons why the current gilded standard surgical handling for an ACL injury in an able-bodied patient is ACL reconstruction with autograft from either the hamstrings or patella tendon. The results of ACL reconstruction are good (Lai et al. 2022) but current techniques do pose their own challenges and potential issues. These include decreased hamstrings forcefulness (Holsgaard-Larsen et al. 2022; Konrath et al. 2022; Setuain et al. 2022), anterior knee pain (Xie et al. 2022) and loss of proprioception (Zhou et al. 2008) There is also meaning bear witness to advise that ACL reconstruction does not forbid future osteoarthritis (Ajuied et al. 2022; Adravanti et al. 2022).

And so, is there a better solution? It stands to reason that past preserving and repairing native tissues and negating the need for autograft that main ACL repair may represent a key step change in the treatment of ACL injuries. In particular, negating the requirement for autografts would theoretically solve troublesome donor site morbidity bug such as loss of hamstrings force and inductive knee pain. Current practices and trends towards remnant preservation and some of the improvements shown in subjective proprioceptive outcomes, knee stability and revision rate (Takazawa et al. 2022; Takahashi et al. 2022; Muneta and Koga 2022; Andonovski et al. 2022) can be extrapolated to offer hypothetical benefits for primary repair over reconstruction.

The interesting question that now arises is that if ligament repair has theoretical advantages over reconstruction and then why is it that reconstruction is the current gold standard? In order to be able to answer this question it worth considering the history of primary ACL repair and how we accept got to the nowadays-day situation.

History of primary ACL repair

ACL injuries were apparently beginning described by the Ancient Greeks (Davarinos et al. 2022). The first main ACL repair was reported in 1895 by Mayo Robson (van der Listing and DiFelice 2022). He describes reattaching both cruciate ligaments from their femoral attachment sites using catgut ligatures. Primary ACL repair was refined farther and eventually open primary ACL repair became the gold standard for ACL treatment in the 1970s and 1980s (England 1976; Feagin and Roll 1976; Weaver et al. 1985; Sherman and Bonamo 1988).

Although initial results for master open up ACL repair were positive (England 1976; Weaver et al. 1985; Sherman and Bonamo 1988) significant issues began to materialize at mid-term follow up with re-rupture rates of > 50% being reported at 5 years (Feagin and Curl 1976). In addition, ACL reconstruction was existence developed and several randomized controlled trails were showing improved outcomes with reconstruction versus chief repair (Andersson et al. 1991; Engebretsen et al. 1990; Grontvedt et al. 1996). As a event, by the 1990s open ACL repair was most completely abandoned in favour of ACL reconstruction.

Yet, it is worth understanding that this paradigm shift was complicated by other factors, which are well highlighted by van der Listing and Di Felice (2016). They state that at that place were a variety of factors that came together to cause the shift from principal repair to reconstruction. In particular, the key issues to annotation include chief repair originally being developed and refined as an open up procedure with resultant morbidity from the arthrotomy itself. Arthroscopic techniques just became more than advanced and refined in the 1990s; in one case primary repair had already been abandoned.

Additionally, rehabilitation protocols have inverse significantly with early mobilization again existence developed after the abandonment of chief repair.

Van der List and Di Felice are also critical of Feagin and Curl'southward piece of work, which is oft quoted every bit show against master repair. In item, the now obsolete surgical technique including the use of figure-of-eight absorbable sutures secured over the iliotibial band was thought to be a contributing gene to the poor outcomes reported by Feagin and Curl 1976.

Finally, and perchance most importantly, much of the early work regarding ACL repair did not take into account tear location. We at present know that tear location has a pregnant bearing on the issue of principal ACL repair (Sherman et al. 1991). Many of the big randomised controlled trials comparing repair with reconstruction practise not accept into account this factor (Drogset et al. 2006). Sherman et al. (1991) showed that "poor tissue quality, typical of mid-substance tears" had much poorer results than type i (proximal tears) which trended towards meliorate results with chief repair. However, much of the piece of work washed before 1991 practice not stratify their results with relation to tear location and thus a significant degree of confounding is introduced into these studies (Strand et al. 2005; Meunier et al. 2006).

All of these factors appear to have contributed to the almost total abandonment of primary ACL repair with no new cohorts of patients existence studied for near two decades. Information technology is only within the last ii years that there has been a significant increment in interest for principal ACL repair with new case series being published (van der van der List and DiFelice 2022; Achtnich et al. 2022).

New primary ACL repair techniques

Although reconstruction is currently the golden standard, primary repair, if successful, tin can theoretically atomic number 82 to a significant improvement in the treatment of ACL injuries in the athlete. In particular, the improvements in memory of proprioception and native kinematics could be a significant advocacy.

Novel techniques for chief ACL repair have developed considerably in recent years (Kohl et al. 2022; MacKay et al. 2022) and now employ the full gambit of advanced arthroscopic techniques currently available. In addition, the improvements in Magnetic Resonance Imaging (MRI) has meant that nosotros are now able to accurately delineate tear location and thus place those patients who are most likely to benefit from chief ACL repair (Daniels et al. 2022; van der List et al. 2022).

A recent instance series (DiFelice et al. 2022), although small (n = xi), does bear witness expert results at medium term follow up with only 1 reported re-rupture following chief repair of proximal ACL tears. A further case control study (Achtnich et al. 2022) compared 20 patients with proximal ACL tears that had primary arthroscopic repair with 20 patients with proximal ACL tears that had unmarried bundle ACL reconstruction. They reported excellent stability testing and patient reported effect in both groups but there was a significantly college revision charge per unit (fifteen% vs 0%) in the primary repair group.

Therefore, it appears that chief ACL repair is a potential treatment selection in specific patients with proximal ACL tears. Even so, a revision charge per unit of 15% is still non satisfactory and non entirely different to results from many years ago that led to the most-abandonment of primary ACL repair. So tin anything be done to amend these results or is history doomed to repeat itself?

Principles of osteosynthesis dictate that bone healing in fractures needs a suitable mechanical and biological environment to occur and that our aim equally orthopaedic and trauma surgeons is to effort and provide that environment through whatever techniques and implants are required. It surmises that a similar principle should use for soft tissue injuries, such as ACL tears. The optimum environment is yet to be identified, merely information technology is axiomatic, as with fracture healing that an chemical element of mechanical stability (Murray et al. 2022a; Seitz et al. 2022) and favourable biology (Mastrangelo et al. 2022; Murray et al. 2022b) are pre-requisites.

As discussed previously, primary ACL repair, as a surgical procedure, has non gone through significant development and refinement and there remain several unanswered issues. A variety of additional techniques and adjuncts have been used in social club to attempt and ameliorate the outcomes and reduce re-ruptures compared to the techniques originally first described in the 1970s and 1980s. Many of these focus on being able to create a satisfactory mechanical and biological environment to allow healing to occur.

Mechanical stability

Animal studies (Fleming et al. 2008) showed that repairing a torn ACL to the tibial stump, does non improve sagittal plane laxity intra-operatively. The likely reasons for this are due to the inherent difficulties in placing a stitch in a short ligament stump composed primarily of longitudinal fibres. Even with grasping suture techniques there is likely to be significant suture sliding along longitudinal fascicles. However, anchoring of the suture to the tibial ACL footprint, particularly centrally/anteriorly did restore sagittal plane laxity, thus suggesting that a suture bridge from the tibial to the femoral side is crucial in restoring and maintaining early sagittal airplane stability.

Additionally, porcine models have demonstrated increased strength with not-absorbable sutures (Vavken et al. 2022). Subsequently, it was found that augmenting the primary ACL repair with a polyethelene tape in a sheep model yielded improved biomechanical properties of the repaired ACL in the form of increased tensile strength and graft stiffness (Seitz et al. 2022). It is perhaps, these studies and ideas that have led to the evolution of two new techniques in ACL repair. Both involve the utilise of a non-absorbable polyethylene tape / wire to bridge the repaired ligament from the femoral to the tibial side.

Internal brace ligament augmentation (IBLA)

Internal Caryatid Ligament Augmentation (IBLA) involves using a two.v mm polythethylene tape to bridge from the anatomical attachments of the mid-bundle positions of the ACL on both the femur and the tibia (Fig.i). All-encompassing micro-fracturing is then carried out on the femoral side to help stimulate biological healing.

Internal Brace Ligament Augmentation (Arthrex™)

Mackay et al. (2015) have performed 68 acute ACL repairs with IBLA since 2022. They draw acutely repairing (inside iii months of injury) femoral-sided avulsions (mid substance tears were reconstructed) with the IBLA technique. A whipstitch was passed through the ligament. The whipstitch and internal brace were secured on the proximal side with the ACL tightrope (Arthrex, Naples, Florida) and distal fixation was achieved with the SwiveLock Suture Anchor (Arthrex, Naples, Florida). Tensioning of the internal brace was carried out with the knee in extension.

They demonstrated similar patient related outcome scores (PROMS) to traditional ACL reconstruction techniques at i twelvemonth follow up. The re-intervention rate was six% simply there was only 1 failure (re-intervention charge per unit for failure 1.5%). The failure occurred at eighteen weeks afterward return to full contact sports. No boosted imaging was carried out to ascertain whether the repair was successful merely in the other cases that required re-intervention (stiffness, recurrent meniscal pathology and patellofemoral osteochondral lesion) the repairs were all plant to be intact.

Therefore, although a limited serial, it appears that IBLA is an interesting potential solution to the loftier failure rates previously associated with ACL repairs. It stands to reason that the mechanical protection afforded past the internal caryatid may allow for comeback in ligamentous healing. Interestingly, IBLA apply has widened with reports of use in paediatric ACL repairs (Smith et al. 2022) and Medial Collateral Ligament (MCL) repairs (Lubowitz et al. 2022).

Dynamic Intraligamentary stabilisation (DIS)

Dynamic Intraligamentary stabilisation (DIS) (Fig.2), developed in Berne (Switzerland), shares the concept of trying to provide a suitable protective mechanical surround in order to assistance with ligamentous healing.

Dynamic Intraligamentary Stabilisation (Mathys Medical™)

The procedure itself involves use of a threaded sleeve contains a preloaded leap and a mechanism for securing the jump in the tibia. A ane.eight mm braided polyethylene (PE) wire, fastened to the tibial component, traverses the knee joint articulation, through the heart of the torn ACL. Information technology exits out of the lateral aspect of the distal femur, where it is secured with a button. Again, extensive microfracturing is performed at the femoral footprint.

The implant once inserted and tensioned applies a constant posterior drawer strength to the proximal tibia. The inbuilt machinery, by assuasive 8 mm of dynamic excursion, ensures that there is a continuous tension of the cord over the entire range of motility.

Biomechanical studies in cadaveric specimens showed that DIS was capable of creating (Kohl et al. 2022) and maintaining sagittal plane stability throughout a normal rehabilitation protocol (Häberli et al. 2022). Therefore, DIS may protect the primary repair whilst assuasive a full range of motion and full weight bearing immediately mail-operatively in concordance with active rehabilitation protocols that have been employed so successfully in patients postal service ACL reconstruction.

Still, in practice, initial results have been mixed thus far. Functional and objective clinical improvement with DIS has been comparable with ACL reconstruction (Henle et al. 2022; Büchler et al. 2022; Schliemann et al. 2022; Meister et al. 2022) simply there is currently little testify directly comparing DIS and ACL reconstruction with respect to improvements in donor site morbidity or proprioception.

Where DIS appears to brand a departure is decreasing time from injury to surgery. Current practise is to carry out DIS in patients within iii weeks of injury.

Not just has this led to an earlier render to work (Bieri et al. 2022) but besides had the significant benefit of meniscal preservation. In a matched study (Bieri et al. 2022) meniscal intervention rates between DIS and ACL reconstruction were similar (53% vs 60% respectively) but the rate of meniscal repair (vs partial resection) was significantly higher in the DIS grouping (49% vs 15% respectively). The hypothesis is that early intervention prevents deposition of the meniscal tissue making it more acquiescent to repair. This correlates with findings of improved outcomes with early ACL reconstruction with less meniscal and chondral pathology detected in the early intervention groups (Goradia and Grana 2001; Fithian et al. 2005; Laxdal et al. 2005).

Although DIS appears to slightly expensive option there accept been suggested overall price benefits with regards to Quality Adjusted Life Years, which appear to exist primarily due to the reduced costs associated with revision DIS compared with revision ACL reconstruction (Bierbaum et al. 2022).

However, multiple instance serial have shown early re-rupture rates appears to be in the region of 4–15%. (Henle et al. 2022, 2022; Büchler et al. 2022; Meister et al. 2022). Although information technology is interesting to notation that these repairs are being carried out on mid-substance likewise every bit proximal tears (Kohl et al. 2022), which we know to exist less favourable to ACL repair techniques (Sherman et al. 1991; Evangelopoulos et al. 2022; Henle et al. 2022; van Eck et al. 2022; Krismer et al. 2022). The current evidence suggest that take a chance factors for revision surgery after DIS include younger age, higher activeness level, increased AP laxity post operatively and central tear locations (Henle et al. 2022; Krismer et al. 2022), thereby making the procedure potentially unsuitable for loftier level athletes.

The other central issue with DIS appears to be high rates of implant removal that are required, with rates of up to 50% reported, due to local discomfort. Although interestingly these are being removed under local anaeasthetic and there may be a bias towards intervention due to the simplicity of the procedure (Häberli et al. 2022). In that location is no proposition of increased failure rate with hardware removal (Bieri et al. 2022; Ateschrang et al. 2022).

Finally, there appear to be a meaning requirement (1.5 to 10%) for intervention for fixed flexion deformity necessitating manipulations under anaesthetic or arthroscopic arthrolysis (1.5 to x%) (Henle et al. 2022, 2022; Kohl et al. 2022; Bieri et al. 2022; Krismer et al. 2022; Häberli et al. 2022). It is unclear what the reasons are just all-encompassing notch scar formation has been noted postal service repair and has been hypothesised as the possible cause (Ateschrang et al. 2022).

Overall, re-intervention rates appear high (40–50%) and midsubstance tears in high activeness level patients pose the biggest risk for failure with DIS and currently no functional or objective clinical improvements take been noted compared with ACL reconstruction controls.

Biologically enhanced repair

Thus far we accept talked about techniques such equally IBLA and DIS, which aim to aid in improving the mechanical surround. Although, initial results show an improvement from the > 50% failure rates reported past Feagin and Curl 1976, in that location is conspicuously all the same some room for improvement with failure rates of up to 15% seen with these new techniques. Perchance information technology is more than uncomplicated mechanics that needs addressing?

We will now go on to hash out some of the techniques for then called biologically enhanced repairs, which are currently in the offing, and aim to provide biological supplementation to help ligamentous healing.

Bio-scaffolds

The introduction of hydrogels, over two decades ago, was one of the initial forays into the utilize of bioscaffolds, for use in tissue replacement or as a carrier for growth factors. They have structural similarities to the extracellular matrix of most connective tissues (Drury and Mooney 2003).

There have besides been several studies looking into the use of Hyaluronan on anterior cruciate ligament healing. In an fauna written report, Hyaluronan was used as an intra-articular injection in partially transected ACLs in rabbits. Histologic evaluation at 12 weeks showed increased collagen blazon III, more than angiogenesis and less inflammation in the test grouping and overall, an improved repair (Wiig et al. 1990). Hyaluronan has as well been used to deliver growth factor for ligament healing (Drupe and Green 1997) only in that location is no electric current literature to support the utilize of hyaluranon in vivo to supplement primary ACL repair.

Apart from Hyaluronan, engineered collagens have also been used as bio-scaffolds. Robayo et al. 2022 in an in vitro report used a tissue engineered collagen scaffold as a healing platform for ruptured ACLs. Their laboratory experiments showed colonisation of fibroblasts within the implanted collagen scaffold. In an in vivo report, on Yucatan minipigs, the use of collagen patches in ACL repairs failed to show superiority in biomechanical testing of the repaired ligaments compared to suture repair only. Histologic evaluation of the test group did not show significant differences in the Ligament Tissue Maturity Alphabetize compared to the control grouping (Fleming et al. 2022). Yet, some other study from the same institute showed cruciate ligament repair augmented with collagen platelet composite patches resulted in improved biomechanical and histo-chemic characteristics of the repaired ligament (Joshi et al. 2009).

Therefore, information technology appears that the addition of platelets to the collagen scaffold appears to be necessary for the collagen scaffold to be effective. The collagen scaffold itself is non sufficient on its own. Interestingly, in a minor instance control written report, addition of a collagen patch to repaired ACL midsubtance tears decreases re-rupture rate and extension arrears (Evangelopoulos et al. 2022), possible through improvements in ligament healing rates and less disordered scar germination in the notch (Ateschrang et al. 2022).

Platelets and platelet rich plasma (PRP)

PRP has received meaning attending in recent years particularly in the field of musculoskeletal pathologies. PRP has more than 3 times the normal concentration of human platelets in plasma and carries important cytokines including Platelet Derived Growth Cistron (PDGF), Transforming Growth Factor (TGF) and Vascular Endothelial Growth Factor (VEGF) (Fleming et al. 2022).

Yoshida and Murray (2013), in an in vitro report, showed ACL fibroblasts that accept been exposed to peripheral blood mononuclear cells and PRP for ii weeks brandish increased cell activity in the course of proliferation, cistron expression and collagen production. Cheng et al. (2010) also showed that both platelets and plasma proteins are necessary to increase collagen gene expression in fibroblasts, a necessary part of ligament healing. Nevertheless, injection of PRP did not translate into improved biomechanical forcefulness of the Anterior Cruciate Ligament repair (Murray et al. 2009).

However, Murray et al. (2006) did demonstrate that PRP combined with a collagen scaffold, resulted in improved biomechanical and histological characteristics of the repaired ACL in a canine model. In the subsequent publication, the authors demonstrated meliorate biomechanical strength after collagen-PRP enhanced repair of porcine ACLs compared to suture repair but (Murray et al. 2007). Therefore, it appears that the collagen scaffold is an essential component in enhancing the effects of PRP. This may get across simply providing a mechanical scaffold as collagen causes a sustained release of anabolic cytokines such as PDGF, TGF and VEGF, which may be an additional contributory cistron.

And then it appears that PRP injected in to a collagen scaffold may exist a suitable method of bio-enhancement. Yoshida et al. (2014) and Fleming et al. (2015) take done further work in order to place the required platelet concentration. It appears that a platelet concentration like to whole blood is what is required for collagen gene expression past ACL fibroblasts. Increasing platelet concentrations actually resulted in an inhibitory upshot on collagen gene expression and also led to college cell apoptosis. Therefore, platelet concentration needs to be controlled and the optimum concentration in human patients needs to be identified in order to create a solution that provides the optimum biological environment for ligamentous healing.

Stem cells

The inductive cruciate ligament has mesenchymal stalk cells (MSCs) that are mainly located close to the blood vessels and within the collagenous structure of the tissue. They have similar characteristics to bone marrow stem cells in the course of growth pattern, morphology, osteogenic and adipogenic capacity; even so they are not completely identical, as MSCs originating from ACLs show less proliferation and chondrogenic capacity (Steinert et al. 2022).

Comparison of MSCs obtained from the ACL, as an intra-articular ligament, and medial collateral ligament (MCL), as an extra-articular ligament, showed significant characteristic differences. ACL stem cells showed slower growth and less differentiation potential than those from the MCL (Zhang et al. 2022). MSCs added to the natural or biodegradable scaffolds or ACL reconstruction grafts promote collagen type I and type III production within the ligament (Ge et al. 2005).

Kanaya et al. 2007 showed that intra-articular injection of cultured bone marrow MSCs in partially transected ACLs in rats accelerated healing and increased ultimate failure load of the ligament in biomechanical testing. Furthermore, Oe et al. 2022 investigated the effect of MSCs on partially transected ACLs in rats by intra-articular injection of bone marrow or mesenchymal derived stem cells. Both biomechanical and histological assessment at 4 weeks showed near normal findings and a significant improvement compared to the command group.

Numerous pre-clinical studies investigated the furnishings of MSCs on graft integration after ACL reconstruction. Some studies reported increased failure load and a fibro-cartilaginous zone at the os-graft interface after ACL reconstruction in the presence of MSCs, compare to fibrous scar tissue in the command group (Ouyang et al. 2004; Lim et al. 2004; Soon et al. 2007; Matsumoto et al. 2022). In a step further, Figueroa et al. (2014) in a pre-clinical written report showed one in 3 ACLs undergoing primary repair with collagen bio-scaffold and MSCs had complete regeneration of the ligament on histological evaluation at 12 weeks.

We have shown that there are several promising studies for bio-enhancement of ACL repairs with a combined form of PRP / MSC s/ bio-scaffold for master intra-articular ligament repair. Murray et al. (2013) have demonstrated that this bio-enhanced repair has comparable biomechanical properties to ACL reconstruction.

Additionally and perchance crucially, they have even shown that using a bioactive scaffold, equally office of a master ACL repair technique, can prevent post-traumatic osteoarthritis, something that has never been demonstrated with ACL reconstruction (Murray and Fleming 2022).Whether this is due to retained proprioception and therefore preserved kinematics and normal joint loading; protective growth factors released from platelets or another every bit even so undefined mechanism is however not known and is the focus of further piece of work. Stage 1 trials for bridge-enhanced ACL repair have shown good results with ten patients. Stage 2 trials are currently in progress (Span-Enhanced™ ACL Repair Trial).

Conspicuously more than work needs to exist done in club to translate these preliminary findings into clinical exercise but it does announced that biological augmentation will have a role to play in primary ACL repair and that main ACL repair could represent a significant advancement in the management of ACL injuries.

Timing of surgery

If this is the case nosotros demand to consider timing of surgery. Animal studies have shown that at that place is a significant reduction on repair strength with delays of even two weeks (Magarian et al. 2022) showing a xl% decrease. This obviously poses its ain obstacles when translating to clinical practice with significant delays to diagnosis and operative intervention. All of the large electric current case series have had ACL repair performed inside 3 weeks of index injury.

Early surgery appears to facilitate meniscal preservation and earlier return to work (Bieri et al. 2022). Nevertheless, there is nothing to propose that this do good is unique to DIS every bit like benefits take been noted with early ACL reconstruction (Goradia and Grana 2001).

Conclusions

We have used the anterior cruciate ligament equally a microcosm of ligamentous repair techniques in athletic patients as it represents item, unique challenges and difficulties when because primary repair. Primary ACL repair has clear theoretical benefits over ACL reconstruction, particularly relevant in high performing athletes. Historical factors meant that primary repair was abandoned in favour of reconstruction and until recently has not been given much attention. Yet, recent piece of work has demonstrated the potential for significant benefits with primary repair in animal models including the possible chondroprotective benefits of bio-enhanced repair techniques.

When considering suitability for principal repair it appears that femoral sided avulsions should be the initial focus, although attempts have been made to repair mid-substance tears and even a case report of a tibial sided soft-tissue avulsion beingness repaired (Sheth et al. 2022). Significant caution is advised with mid-substance tears as significantly higher failure rates have been shown (Sherman et al. 1991; Evangelopoulos et al. 2022; Henle et al. 2022; van Eck et al. 2022; Krismer et al. 2022).

We would also circumspection confronting using a suture repair technique lonely, every bit they take been associated with high failure rates. We would recommend attempts exist made to endeavor and create the ideal mechanical and biological environment for healing to occur and for the repairs to exist performed as acutely as possible from the time of injury. This would also appear to confer boosted benefits with regards to meniscal preservation (Bieri et al. 2022).

Use of polyethylene tapes or wires that span the course of the ligament from the femur to the tibia appear to have had some initial success and information technology remains to exist seen whether static stability with IBLA is sufficient or if a more dynamic arroyo, such as DIS is necessary.

It appears bio-enhancement of the ACL repair with a collagen scaffold infused with PRP or MSCs too shows some hope. There is clearly still some manner to go to determine whether these techniques volition translate to meaning benefits for athletes, especially as they appear to be in a higher take chances group for repair failure (Henle et al. 2022; Krismer et al. 2022). However, with conscientious patient selection failure rates are broadly comparable with ACL reconstruction and several unanswered questions remain that provide avenues for further exploration that may even so yield benefits for repair over reconstruction e.k. how practise outcomes of reconstruction post failed repair compare with outcomes post master reconstruction?

There may well be a new frontier on the horizon for the handling of ACL injuries but information technology may be the non-athlete that leads the way.

Acknowledgments

We would like to acknowledge Arthrex, Naples, Florida and Mathys, Bettlach, Switzerland for providing illustrative material for the IBLA and DIS implant respectively.

Funding

No funding was received for the preparation of this manuscript.

Availability of information and materials

All studies used to codify this commodity are freely available online and readily searchable through PubMed (MEDLINE), EMBASE and Cochrane Library databases. A full list of references is included within the manuscript.

Abbreviations

ACL	Anterior cruciate ligament
DIS	Dynamic Intraligamentary Stabilisation
IBLA	Internal Caryatid Ligament Augmentation
MCL	Medial collateral ligament
MRI	Magnetic resonance imaging
MSC	Mesenchymal stalk jail cell
PDFG	Platelet derived growth factor
PE	Polyethylene
PRP	Platelet rich plasma
TGF	Transforming growth factor
VEGF	Vascular Endothelial Growth Factor

Authors' contributions

PM contributed to the conception, designing, drafting and revising the manuscript. SM contributed to drafting and revising the manuscript. BA contributed to the conception, designing, drafting and revising the manuscript. All authors read and approved the final manuscript.

Notes

Authors data

PM is a specialist registrar in Trauma and Orthopaedics on the North Westward Thames Grooming Programme. He holds a MA from the Academy of Cambridge having completed his research in Clinical Pharmacology. He qualified with MBBS (Distinction) from University College London Medical School.

SM is a specialist registrar in Trauma and Orthopaedics on the South Westward Thames Training Programme. He holds a MD and MSc and his inquiry interests focus on new frontiers in Trauma and Orthopaedic Surgery including the use of stem cells. He has authored a book affiliate on the apply of Bone Marrow Aspirate Concentrate in tendon pathologies.

BA is an orthopaedic surgeon specialising exclusively in human knee surgery. He has a particular interest in sports knee injuries, inductive knee hurting and optimising return to sport. He studied Medicine at University College London and graduated in 2002. In addition to his medical caste, he completed a degree (BSc) in Orthopaedic Science at the Royal National Orthopaedic Hospital. His specialist orthopaedic training was in Cambridge and London. He was made a beau of the Royal College of Surgeons in 2022 and obtained his specialist CCT in 2022. BA in as invited committee member to the European Guild for Sports Traumatology, Genu Surgery and Arthroscopy (ESSKA).

Ethics approval and consent to participate

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Contributor Information

Piyush Mahapatra, Electronic mail: moc.liamg@artapaham.hsuyip.

Saman Horriat, E-mail: moc.liamg@tairroh.namas.

Bobby S. Anand, Email: ku.gro.srotcod@dnanaybbob.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6002325/

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