Abstract
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.1,2 However, relatively high rates of perioperative complications, including arthrofibrosis, residual laxity, graft failure, and the need for revision surgery, have been reported.3, 4, 5
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.6,7 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).8, 9, 10 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.11,12 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.13,14 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/m2), and exact KD grade (according to the Schenck classification of knee dislocations).15 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.11,16
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.16,17
Surgical Technique
The authors’ preference for ACLR with ST augmentation utilizes an all-inside technique with quadrupled semitendinosus-gracilis autograft, or 4-stranded allograft.17 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.17 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.16 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.
Fig 1.
Quadrupled tibialis anterior allograft with independent suture tape (ST) reinforcement. The ST is looped independently in the femoral suspensory button.
Fig 2.
(A) View of the left knee at 90° of flexion through the anterolateral viewing portal with a 30° arthroscope showing peroneus longus allograft posterior cruciate ligament (PCL) reconstruction with suture tape (ST) reinforcement. (B) View of the left knee at 90° of flexion through the anteromedial viewing portal with a 30° arthroscope showing concomitant peroneus longus PCL reconstruction with ST reinforcement and semitendinosus allograft anterior cruciate ligament (ACL) reconstruction with suture tape reinforcement.
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 χ2 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).
Fig 3.
Flowchart of study patients in the suture tape and control cohorts. (ACLR, anterior cruciate ligament reconstruction; PCLR, posterior cruciate ligament reconstruction; PROMs, patient-reported outcome measures; ST, suture tape augmentation; TKA, total knee arthroplasty.)
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) |
NOTE. Data are expressed as mean ± standard deviation (95% confidence interval) or n (%).
KD, Schenck classification grade.
Patient-reported outcome data are presented in Table 3. When analyzing PROMs, 40 patients (80%) were able to be contacted at a minimum 2-year follow-up. Three control patients were excluded from the final statistical analysis of PROM scores due to undergoing a TKA prior to final follow-up. The mean follow-up was 4.7 ± 2.1 years in the ST cohort and 8.5 ± 6.5 years in the control cohort (P > .05). Eighteen patients in the ST cohort were compared against 19 patients in the control cohort. 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), IKDC (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).
Table 3.
Patient Reported Outcomes at Final Follow-Up
| Characteristic | Suture Tape (n = 18) | Control (n = 19) | P Value |
|---|---|---|---|
| Mean follow-up, y | 4.7 ± 2.1 | 8.5 ± 6.5 | .126 |
| IKDC score, points | 75.7 ± 3.9 (68.1-83.3) | 76.3 ± 5.9 (64.8-87.8) | .370 |
| Lysholm score, points | 81.8 ± 3.6 (74.8-88.8) | 77.6 ± 5.4 (67.0-88.2) | .910 |
| Tegner Activity score, points | 4.8 ± 0.6 (3.7-5.9) | 5.4 ± 0.4 (4.7-6.2) | .365 |
| VAS pain score, points | |||
| At rest | 0.9 ± 0.4 (0.1-1.7) | 1.5 ± 0.6 (0.3-2.7) | .707 |
| With use | 3.0 ± 0.6 (1.9-4.1) | 2.2 ± 0.6 (1.0-3.4) | .243 |
NOTE. Data are expressed as mean ± standard deviation (95% confidence interval).
IKDC, International Knee Documentation Committee; VAS, visual analog scale.
Complications and reoperations are listed in Table 4. A total of 28% of the suture tape patients (7 of 25) and 32% of the control patients (8 of 25) had a reoperation. In total, 3 patients in each of the ST (12%) and control cohorts (12) underwent revision ACL and/or PCL reconstruction (Table 4). Reoperations in the ST cohort included 1 wound revision and keloid excision, 2 arthroscopic lysis of adhesions, 1 partial lateral meniscectomy with chondroplasty, and 2 multiligament knee reconstruction revision surgeries (1 patient with ACL/PCL/lateral cruciate ligament revision at 3 years postoperatively due to a noncontact hyperextension injury and 1 patient with ACL/medial cruciate ligament revision at 1 year postoperatively following a noncontact pivoting injury). One patient in the ST cohort went on to require a TKA due to posttraumatic osteoarthritis at 6 years postoperatively. Two patients in the control cohort developed an infection requiring irrigation and debridement, 1 patient underwent reoperation for a lateral meniscus tear, and 1 patient underwent 2 subsequent ACLR revisions following sports-related injuries. One patient underwent a high tibial osteotomy with revision ACLR, lateral meniscus root repair, medial femoral condyle chondroplasty, and an iliotibial band tenodesis 1.5 years postoperatively. Three patients in the control cohort went on to require TKA due to posttraumatic osteoarthritis at a mean of 12.3 years.
Table 4.
Reoperation Procedures
| Characteristic | Suture Tape (n = 25) | Control (n = 25) |
|---|---|---|
| Reoperations | 7 (28) | 8 (32) |
| Reoperation procedures∗ | ||
| TKA | 1 | 3 |
| PCLR | 1 | 0 |
| ACLR | 2 | 3 |
| MCLR/PMCR | 1 | 0 |
| LCLR/PLCR | 1 | 1 |
| LM | 1 | 2 |
| MM | 1 | 1 |
| HTO | 0 | 1 |
| Chondroplasty | 1 | 1 |
| Lysis of adhesions | 2 | 0 |
| Wound revision | 1 | 0 |
| Iliotibial band tenodesis | 0 | 1 |
| Irrigation/debridement | 0 | 2 |
NOTE. Data are expressed as n (%).
ACLR, anterior cruciate ligament reconstruction; HTO, high tibial osteotomy; LCLR, lateral cruciate ligament repair or reconstruction/posterolateral corner reconstruction; LM, lateral meniscus repair/meniscectomy/root repair; MM, medial meniscus repair/meniscectomy; PCLR, posterior cruciate ligament reconstruction; MCLR/PMCR, medial cruciate ligament repair or reconstruction/posteromedial corner reconstruction; TKA, total knee arthroplasty.
Multiple procedures may have been performed at each reoperation.
Discussion
The major findings of this study are that ST augmentation during concomitant ACLR/PCLR produced similar clinical outcomes, PROM scores, and postoperative clinical laxity compared to without ST augmentation. There were no significant differences in the number of revisions or reoperations between groups and no evidence of increased implant-related perioperative complications.
Several options exist when considering technique and graft choice for combined ACLR/PCLR, including both autograft and allograft bone–patellar tendon–bone, quadriceps and hamstring tendons, Achilles tendon allografts, and single- or double-bundle techniques.18, 19, 20 No single graft or technique choice has shown superior clinical outcomes in the literature. While technically challenging to perform, several investigations have demonstrated that MLKI reconstructions, including combined ACL/PCL procedures, can successfully address clinical instability, with some studies reporting satisfactory outcomes and low revision rates up to 15 years postoperatively.21, 22, 23 Notably, patients obtain good overall function and return to activity despite incomplete restoration of normal knee kinematics and some degree of residual laxity.22, 23, 24 The primary role of the PCL is to resist posterior translation of the tibia relative to the femur, with both anterolateral and posteromedial bundles contributing throughout the range of motion of the knee.25 In our analysis, postoperative posterior drawer testing results did not differ among cohorts. However, residual PCL laxity after PCLR can be a difficult outcome to quantify postoperatively.26 Clinical examination maneuvers, such as the posterior drawer test, have shown sensitivity and specificity of greater than 90% in detecting PCL insufficiency.27 That being said, more subtle laxity may be more difficult to detect, as examination accuracy increases with higher-grade injuries.27 Particularly in the setting of bicruciate injuries or other MLKIs, accurately detecting and quantifying pathologic laxity can pose a significant clinical challenge and requires substantial experience managing these complex injuries.
To our knowledge, this investigation is the first to report the clinical results of a direct comparison of patients undergoing combined ACL/PCL reconstruction with ST augmentation versus a matched control cohort without ST augmentation. Prior available studies have evaluated single case series of multiligamentous knee reconstructions augmented with ST, in the absence of matched controls, or performed systematic reviews of the literature where any study that utilized suture tape augmentation during multiligamentous knee reconstruction was included.13,14 In our analysis, patients in the ST augmentation group reported similar postoperative VAS, Tegner activity scale, Lysholm, and IKDC scores compared to patients without ST augmentation, with PROM values on par with prior studies.19,20,28 Implementing a 1:1 propensity matching methodology by age, sex, BMI, and exact KD classification minimizes the potential impact of demographic differences while comparing similar injuries of the same severity. Additionally, no significant differences in concomitant preoperative neurovascular, meniscal, or chondral injuries were noted between the groups. Younger patients under 30 years of age have been reported to experience increased functional outcome scores compared to older patients at short- to mid-term follow-up after MLKI reconstruction, but these differences have not been proven to be maintained at a minimum 10-year long-term follow-up.23,29 When considering the presence of a preoperative neurovascular injury, patients who sustained an associated popliteal artery injury requiring bypass grafting produced significantly lower clinical knee outcome scores at a mean of 6 years postoperatively versus patients without vascular injury.30 Interestingly, some evidence has shown that although patients with a partial common peroneal nerve palsy are more likely to recover antigravity strength than patients with a complete nerve injury, overall postoperative clinical knee function after MLKI reconstruction is similar between those with a nerve injury and those without.31
Safety concerns and the potential for implant-related perioperative complications must be considered when contemplating ST augmentation during ACL or PCL reconstruction. Since the 1980s, synthetic devices designed to augment or replace ACL grafts during reconstruction have appeared on the market.7 However, these implants were associated with unacceptably high failure rates.32, 33, 34, 35 Although the independent suture tape is designed to protect the graft from supraphysiologic load, concern exists regarding the potential for suture tape overtensioning or graft stress-shielding.6,36 These issues can theoretically lead to overconstraint of the graft, decreased stability, hindrance of the graft ligamentization process, and increased risk of graft failure.37 However, a biomechanical study by Bachmaier et al.36 showed that the suture tape acted as a “load-sharing” device, as loads within the graft were noted even with peel forces. In the present analysis, both the ST augmentation and nonaugmentation cohorts experienced similar rates of reoperation. Additionally, there were no differences in the number of postoperative complications or any evidence of implant-related complications among the ST augmentation cohort. These findings support that although theoretical safety concerns over ST augmentation are plausible, clinical impact remains to be realized. The results of the present investigation align well with the available, albeit limited, body of clinical evidence regarding ACL or PCL reconstruction augmented with independent ST fixation that shows no increases in graft failure or implant-related perioperative complications.16,17,38,39
Recent biomechanical and clinical investigations have shown that ST augmentation in PCL reconstruction can produce superior clinical outcome scores, return to activity, and postoperative clinical laxity compared to traditional techniques, as well as improved postoperative clinical laxity.11,12,16 However, the potential impact of ST augmentation on graft failure rate remains less clear. In our analysis, we found no differences in terms of clinical outcome scores, clinical laxity, or reoperation rates in patients who underwent combined ACLR/PCLR with versus without ST. This potentially could have been influenced by the severity of injury since combined cruciate reconstruction may not necessarily produce equivalent results as isolated PCL reconstruction. Additionally, while there were no differences found in postoperative clinical laxity among ST and control patients, objective data from stress radiographs could have allowed for a more precise evaluation of posterior tibial translation and potentially different results. Cost-effectiveness of ST augmentation is another clinically relevant issue that must be considered. While efforts to augment the biological environment and mechanical strength of cruciate ligament reconstruction have been described, some techniques, such as the addition of bone marrow aspirate concentrate and demineralized bone matrix, can add approximately $2,000 to the cost of each procedure.40 Some authors argue that the cost of ST augmentation alone is minimal compared to other reconstruction augmentation methods via orthobiologics, particularly if the addition of the ST leads to fewer graft failures.41 In our analysis, there were no differences in graft failure when evaluating for excessive postoperative clinical laxity or revision rate when comparing combined ACLR/PCLR with or without ST augmentation. While the final cost is multifactorial, depending on individual factors such as institution setting and geographic location, it is important to consider potential increases in surgical cost and operative time when contemplating ST augmentation. While ST augmentation may increase the biomechanical strength of cruciate reconstruction, larger randomized clinical trials with long-term follow-up are warranted to assess whether ST augmentation influences postoperative graft failure rate.
Limitations
Our study is not without limitations. Heterogeneity of graft choices could not be accounted for and was left to surgeon preference. The retrospective nature of the study design also inherently limited the level of analysis. The matching criteria used in this investigation were implemented to allow for direct comparisons of knee injuries by matching by exact KD grade among 2 patient cohorts of similar demographics. However, this subsequently limited the sample size of our final cohorts. A larger sample of patients may potentially have allowed for greater detection of differing outcomes between cohorts or the occurrence of additional complications. The PROMs utilized in this study may possess a ceiling effect, whereby smaller, yet clinically impactful, differences in outcomes may not be captured once a certain threshold score is achieved. Furthermore, contacting patients via telephone for final follow-up has the potential for recall bias. Additionally, the follow-up times between the ST cohort and the control cohort varied substantially because ST augmentation was a newer adopted practice. Even though follow-up time was not statistically significant between the 2 cohorts, the difference may have impacted PROMs. Finally, the risk of inter- and intrarater variation in clinical performance of examination maneuvers cannot be eliminated. While objective data from stress radiographs or other methods, such as KT-1000 testing, would have significantly contributed to the evaluation of postoperative clinical laxity, these were not readily available to provide a statistically sound comparison between matched patients.
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.
Disclosures
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: A.J.K. is a paid consultant for Arthrex, is a member of the editorial or governing board for the American Journal of Sports Medicine and Springer, receives research support from Aesculap/B. Braun, receives IP royalties from Arthrex, and is a board or committee member of the Arthroscopy Association of North America and the International Cartilage Repair Society. B.A.L. is a consultant or advisor for Arthrex, has equity or stocks with COVR Medical, and is a board member of the Journal of Knee Surgery, Orthopedics Today, and Knee Surgery, Sports Traumatology, Arthroscopy. All other authors (A.J.T., B.C., S.I., A.V.D., J.J.K.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
References
- 1.Levy B.A., Dajani K.A., Whelan D.B., et al. Decision making in the multiligament-injured knee: An evidence-based systematic review. Arthroscopy. 2009;25:430–438. doi: 10.1016/j.arthro.2009.01.008. [DOI] [PubMed] [Google Scholar]
- 2.Peskun C.J., Whelan D.B. Outcomes of operative and nonoperative treatment of multiligament knee injuries: An evidence-based review. Sports Med Arthrosc Rev. 2011;19:167–173. doi: 10.1097/JSA.0b013e3182107d5f. [DOI] [PubMed] [Google Scholar]
- 3.Cook S., Ridley T., McCarthy M.A., et al. Surgical treatment of multiligament knee injuries. Knee Surg Sports Traumatol Arthrosc. 2015;23:2983–2991. doi: 10.1007/s00167-014-3451-1. [DOI] [PubMed] [Google Scholar]
- 4.Patel N.K., Lian J., Nickoli M., et al. Risk factors associated with complications after operative treatment of multiligament knee injury. Orthop J Sports Med. 2021;9 doi: 10.1177/2325967121994203. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Alentorn-Geli E., Lazarides A.L., Utturkar G.M., et al. Factors predictive of poorer outcomes in the surgical repair of multiligament knee injuries. Knee Surg Sports Traumatol Arthrosc. 2019;27:445–459. doi: 10.1007/s00167-018-5053-9. [DOI] [PubMed] [Google Scholar]
- 6.Bachmaier S., Smith P.A., Bley J., Wijdicks C.A. Independent suture tape reinforcement of small and standard diameter grafts for anterior cruciate ligament reconstruction: A biomechanical full construct model. Arthroscopy. 2018;34:490–499. doi: 10.1016/j.arthro.2017.10.037. [DOI] [PubMed] [Google Scholar]
- 7.Mackenzie C.E., Huntington L.S., Tulloch S. Suture tape augmentation of anterior cruciate ligament reconstruction increases biomechanical stability: A scoping review of biomechanical, animal, and clinical studies. Arthroscopy. 2022;38:2073–2089. doi: 10.1016/j.arthro.2021.12.036. [DOI] [PubMed] [Google Scholar]
- 8.Levy B.A., Piepenbrink M., Stuart M.J., Wijdicks C.A. Posterior cruciate ligament reconstruction with independent suture tape reinforcement: An in vitro biomechanical full construct study. Orthop J Sports Med. 2021;9 doi: 10.1177/2325967120981875. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Matava M.J., Koscso J., Melara L., Bogunovic L. Suture tape augmentation improves the biomechanical performance of bone-patellar tendon-bone grafts used for anterior cruciate ligament reconstruction. Arthroscopy. 2021;37:3335–3343. doi: 10.1016/j.arthro.2021.04.053. [DOI] [PubMed] [Google Scholar]
- 10.Trasolini N.A., Lindsay A., Gipsman A., Rick Hatch G.F. The biomechanics of multiligament knee injuries: From trauma to treatment. Clin Sports Med. 2019;38:215–234. doi: 10.1016/j.csm.2018.11.009. [DOI] [PubMed] [Google Scholar]
- 11.Zhang H., Wang J., Gao Y., Zheng P., Gong L. Suture tape augmentation improves posterior stability after isolated posterior cruciate ligament reconstruction using hamstring tendon autograft with single-bundle transtibial technique. Arthroscopy. 2024;40:2045–2054. doi: 10.1016/j.arthro.2023.12.007. [DOI] [PubMed] [Google Scholar]
- 12.Levin S.A., Reed L.A., Levy B.A. Editorial Commentary: Clinical and basic science evidence supports the use of suture tape augmentation of posterior cruciate ligament reconstruction. Arthroscopy. 2024;40:2055–2057. doi: 10.1016/j.arthro.2024.02.021. [DOI] [PubMed] [Google Scholar]
- 13.Panish B., Lawson J.J., Elkadi S., Schaefer E., Perraut G., Argintar E.H. Multiligament knee reconstruction with suture tape augmentation: Patient-reported outcomes at minimum 2-year follow-up. Orthopedics. 2024;47:238–243. doi: 10.3928/01477447-20240424-02. [DOI] [PubMed] [Google Scholar]
- 14.Randall A., Pearse R., Khan S., Atkinson H. Use of internal bracing in multi-ligamentous knee injury reconstruction: A systematic review. Indian J Orthop. 2024;58:1518–1527. doi: 10.1007/s43465-024-01260-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Schenck R. Classification of knee dislocations. Oper Tech Sports Med. 2003;11:193–198. [Google Scholar]
- 16.Therrien E., Pareek A., Song B.M., et al. Comparison of posterior cruciate ligament reconstruction using an all-inside technique with and without independent suture tape reinforcement. Orthop J Sports Med. 2022;10 doi: 10.1177/23259671221137357. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Parkes C.W., Leland D.P., Levy B.A., et al. Hamstring autograft anterior cruciate ligament reconstruction using an all-inside technique with and without independent suture tape reinforcement. Arthroscopy. 2021;37:609–616. doi: 10.1016/j.arthro.2020.09.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Mardani-Kivi M., Karimi-Mobarakeh M., Hashemi-Motlagh K. Simultaneous arthroscopic ACL and PCL reconstruction using allograft Achilles tendon. J Clin Orthop Trauma. 2019;10:S218–S221. doi: 10.1016/j.jcot.2019.01.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Colosimo A.J., Carroll P.F., Heidt R.S., Jr., Carlonas R.L. Simultaneous ACL and PCL reconstruction. J Knee Surg. 2003;16:191–196. [PubMed] [Google Scholar]
- 20.Denti M., Tornese D., Melegati G., Schonhuber H., Quaglia A., Volpi P. Combined chronic anterior cruciate ligament and posterior cruciate ligament reconstruction: Functional and clinical results. Knee Surg Sports Traumatol Arthrosc. 2015;23:2853–2858. doi: 10.1007/s00167-015-3764-8. [DOI] [PubMed] [Google Scholar]
- 21.Fanelli G.C., Edson C.J. Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction in the multiple ligament injured knee: 2- to 10-year follow-up. Arthroscopy. 2002;18:703–714. doi: 10.1053/jars.2002.35142. [DOI] [PubMed] [Google Scholar]
- 22.Strobel M.J., Schulz M.S., Petersen W.J., Eichhorn H.J. Combined anterior cruciate ligament, posterior cruciate ligament, and posterolateral corner reconstruction with autogenous hamstring grafts in chronic instabilities. Arthroscopy. 2006;22:182–192. doi: 10.1016/j.arthro.2005.11.001. [DOI] [PubMed] [Google Scholar]
- 23.Boos A.M., Wang A.S., Hevesi M., Krych A.J., Stuart M.J., Levy B.A. Long-term outcomes after surgical reconstruction of multiligamentous knee injuries: Results at minimum 10-year follow-up. Orthop J Sports Med. 2024;12 doi: 10.1177/23259671231223188. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Winkler P.W., Zsidai B., Narup E., et al. Sports activity and quality of life improve after isolated ACL, isolated PCL, and combined ACL/PCL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2023;31:1781–1789. doi: 10.1007/s00167-022-07060-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Lynch T.B., Chahla J., Nuelle C.W. Anatomy and biomechanics of the posterior cruciate ligament. J Knee Surg. 2021;34:499–508. doi: 10.1055/s-0041-1725007. [DOI] [PubMed] [Google Scholar]
- 26.Okoroafor U.C., Saint-Preux F., Gill S.W., Bledsoe G., Kaar S.G. Nonanatomic tibial tunnel placement for single-bundle posterior cruciate ligament reconstruction leads to greater posterior tibial translation in a biomechanical model. Arthroscopy. 2016;32:1354–1358. doi: 10.1016/j.arthro.2016.01.019. [DOI] [PubMed] [Google Scholar]
- 27.Rubinstein J.R.R.A., Shelbourne K.D., McCarroll J.R., VanMeter C.D., Rettig A.C. The accuracy of the clinical examination in the setting of posterior cruciate ligament injuries. Am J Sports Med. 1994;22:550–557. doi: 10.1177/036354659402200419. [DOI] [PubMed] [Google Scholar]
- 28.Zhao J., Huangfu X., He Y., Yang X., Zhu Y. Simultaneous double-bundle anterior cruciate ligament and posterior cruciate ligament reconstruction with autogenous hamstring tendons. Arthroscopy. 2008;24:1205–1213. doi: 10.1016/j.arthro.2008.06.018. [DOI] [PubMed] [Google Scholar]
- 29.Levy N.M., Krych A.J., Hevesi M., et al. Does age predict outcome after multiligament knee reconstruction for the dislocated knee? 2- to 22-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2015;23:3003–3007. doi: 10.1007/s00167-015-3750-1. [DOI] [PubMed] [Google Scholar]
- 30.Sanders T.L., Johnson N.R., Levy N.M., et al. Effect of vascular injury on functional outcome in knees with multi-ligament injury: A matched-cohort analysis. JBJS. 2017;99:1565–1571. doi: 10.2106/JBJS.16.01540. [DOI] [PubMed] [Google Scholar]
- 31.Krych A.J., Giuseffi S.A., Kuzma S.A., Stuart M.J., Levy B.A. Is peroneal nerve injury associated with worse function after knee dislocation? Clin Orthop Relat Res. 2014;472:2630–2636. doi: 10.1007/s11999-014-3542-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Batty L.M., Norsworthy C.J., Lash N.J., Wasiak J., Richmond A.K., Feller J.A. Synthetic devices for reconstructive surgery of the cruciate ligaments: A systematic review. Arthroscopy. 2015;31:957–968. doi: 10.1016/j.arthro.2014.11.032. [DOI] [PubMed] [Google Scholar]
- 33.Dahlstedt L., Dalén N., Jonsson U. Goretex prosthetic ligament vs. Kennedy ligament augmentation device in anterior cruciate ligament reconstruction: A prospective randomized 3-year follow-up of 41 cases. Acta Orthop Scand. 1990;61:217–224. doi: 10.3109/17453679008993504. [DOI] [PubMed] [Google Scholar]
- 34.Tulloch S.J., Devitt B.M., Norsworthy C.J., Mow C. Synovitis following anterior cruciate ligament reconstruction using the LARS device. Knee Surg Sports Traumatol Arthrosc. 2019;27:2592–2598. doi: 10.1007/s00167-018-5280-0. [DOI] [PubMed] [Google Scholar]
- 35.Tulloch S.J., Devitt B.M., Porter T., et al. Primary ACL reconstruction using the LARS device is associated with a high failure rate at minimum of 6-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2019;27:3626–3632. doi: 10.1007/s00167-019-05478-3. [DOI] [PubMed] [Google Scholar]
- 36.Bachmaier S., Smith P.A., Argintar E.H., Chahla J., Higgins L.D., Wijdicks C.A. Independent suture augmentation with all-inside anterior cruciate ligament reconstruction reduces peak loads on soft-tissue graft. A biomechanical full-construct study. Arthroscopy. 2022;38:88–98. doi: 10.1016/j.arthro.2021.09.032. [DOI] [PubMed] [Google Scholar]
- 37.Bedi A. Editorial Commentary: Buckle up surgeons: “Safety belt” reinforcement of knee anterior cruciate ligament reconstruction grafts. Arthroscopy. 2018;34:500–501. doi: 10.1016/j.arthro.2017.12.009. [DOI] [PubMed] [Google Scholar]
- 38.Bodendorfer B.M., Michaelson E.M., Shu H.T., et al. Suture augmented versus standard anterior cruciate ligament reconstruction: A matched comparative analysis. Arthroscopy. 2019;35:2114–2122. doi: 10.1016/j.arthro.2019.01.054. [DOI] [PubMed] [Google Scholar]
- 39.Shantanu K., Singh S., Ratha S., Kumar D., Sharma V. Comparative study of functional outcomes of arthroscopic ACL reconstruction by augmented hamstring graft with Fiber tape and hamstring graft alone: A prospective study. Int J Orthop Sci. 2019;5:165–173. [Google Scholar]
- 40.Lavender C.D., Schaver A.L., Taylor S., et al. Anterior cruciate ligament reconstruction augmentation with bone marrow aspirate concentrate, demineralized bone matrix, and suture tape shows no difference in outcomes—but faster functional recovery—versus non-augmented anterior cruciate ligament reconstruction. Arthroscopy. 2025;41:1496–1508. doi: 10.1016/j.arthro.2024.06.042. [DOI] [PubMed] [Google Scholar]
- 41.Smith P.A. Editorial Commentary: Suture tape augmentation enhances recovery after anterior cruciate ligament surgery and is cost-effective, while biologic augmentation requires well-powered controlled trials. Arthroscopy. 2025;41:1509–1511. doi: 10.1016/j.arthro.2024.09.042. [DOI] [PubMed] [Google Scholar]