Anterior Cruciate Ligament Repair With Internal Bracing Augmentation

The incidence of anterior cruciate ligament (ACL) injuries has rapidly increased, and patients with ACL injuries frequently have concomitant meniscal pathologies. Given the advantages in restoring patient anatomy, retaining proprioceptive fibers, and eliminating risks of donor site morbidity, ACL repair has reemerged as a treatment option for indicated patients. For proximal tears, augmentation of the native ACL with an internal brace has been thought to reinforce ligament strength, facilitate improved ligamentization, and have a protective effect as a secondary stabilizer. As such, there has been a growing interest in improving ACL repair techniques through augmentation with an internal brace implant.

Patients are indicated for surgery when presenting with symptomatic ACL insufficiency, as observed on provocative testing and confirmed by advanced imaging, such as magnetic resonance imaging. Repair can be indicated in acute and proximal tears or subacute-to-chronic, proximal tears in patients with reducible remnant tissue who have persistent instability.

Viewing the ACL from the anteromedial portal, the native ACL was found to be insufficient and avulsed from its femoral attachment. A gentle notchplasty and microfracture of the footprint were performed, taking care to protect and preserve the residual stump. Sutures were passed through both bundles of the ACL, starting distally and progressing proximally toward the avulsed end in an interlocking fashion. The anteromedial bundle footprint was identified and marked on the lateral femoral wall. A tunnel was drilled, and the previously passed sutures were used to restore ACL attachment to the native femoral site. After proximal footprint fixation, an ACL guide was used to drill a tunnel anterior to the native ACL tibial insertion. A suture lasso was placed through this hole, and preloaded fiber tape threads were shuttled with the ACL substance down the tibia. Fixation was achieved with a suture anchor perpendicular to the tibial cortex.

Within 2 years postoperatively, patients are expected to have improved knee-specific quality of life, improved stability, and a successful return to activities.

Advancements in our understanding of the ACL should prompt surgeons to consider ACL repair augmentation techniques to improve outcomes and restore native anatomy in select patients with proximal ACL avulsions.

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.