Research progress of suture augmentation in anterior cruciate ligament reconstruction_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LIU Jiaxin , LI Hongyu , WANG Meng , WANG Yiran , GUO Guanxin ,  ZHANG Hangzhou

Department of Orthopedics, Joint Surgery and Sports Medicine, First Affiliated Hospital of China Medical University, Shenyang Sports Medicine Clinical Medical Research Center, Shenyang Liaoning, 110001, P. R.China;

Corresponding author：

ZHANG Hangzhou, Email: zhanghz1000@163.com

Keywords：

Suture augmentation; anterior cruciate ligament reconstruction; biomaterials; research progress

DOI：

10.7507/1002-1892.202501063

Video：

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Abstract Full text Figures/Tables Video References Cited by

Objective To summarize the research progress of suture augmentation (SA) in anterior cruciate ligament (ACL) reconstruction. Methods A comprehensive review of recent literature at home and abroad SA for ACL reconstruction was conducted. The efficacy of SA in ACL reconstruction was evaluated by examining the definition, biomechanics, and histological studies of SA, along with its clinical application status in ACL reconstruction. Results SA demonstrates significant advantages in enhancing the biomechanical stability of ACL grafts, reducing the risk of re-rupture, and accelerating postoperative recovery. Specifically, SA improves graft stiffness, ultimate failure strength, and cyclic stability, thereby diminishing the risk of early postoperative failure and joint instability. Histologically, it fosters remodeling and tendon-bone integration through early load-sharing mechanisms; however, stress shielding may interfere with natural remodeling processes, warranting further attention. Clinically, SA reduces graft failure rates and the need for revision surgeries, markedly improving knee joint stability and functional recovery in young patients. Nevertheless, its impact on graft maturation and potential complications remains controversial. Conclusion Despite the many advantages of SA in ACL reconstruction, future endeavors should focus on optimizing tensioning techniques, developing bioactive materials, and conducting large-scale randomized controlled trials to further elucidate its clinical value and scope of applicability, providing a more reliable solution for ACL reconstruction.

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8.	van Eck CF, Schkrohowsky JG, Working ZM, et al. Prospective analysis of failure rate and predictors of failure after anatomic anterior cruciate ligament reconstruction with allograft. Am J Sports Med, 2012, 40(4): 800-807.
9.	Conte EJ, Hyatt AE, Gatt CJ, et al. Hamstring autograft size can be predicted and is a potential risk factor for anterior cruciate ligament reconstruction failure. Arthroscopy, 2014, 30(7): 882-890.
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1. Lai VJ, Reynolds AW, Kindya M, et al. The use of suture augmentation for graft protection in ACL reconstruction: A biomechanical study in porcine knees. Arthrosc Sports Med Rehabil, 2020, 3(1): e57-e63.
2. Simon D, Mascarenhas R, Saltzman BM, et al. The relationship between anterior cruciate ligament injury and osteoarthritis of the knee. Adv Orthop, 2015, 2015: 928301. doi: 10.1155/2015/928301.
3. Carey JL, Dunn WR, Dahm DL, et al. A systematic review of anterior cruciate ligament reconstruction with autograft compared with allograft. J Bone Joint Surg (Am), 2009, 91(9): 2242-2250.
4. Alkhalaf FNA, Hanna S, Alkhaldi MSH, et al. Autograft diameter in ACL reconstruction: size does matter. SICOT J, 2021, 7: 16. doi: 10.1051/sicotj/2021018.
5. Kurtoğlu A, Başar B, Başar G, et al. Small size autograft versus large size allograft in anterior cruciate ligament reconstruction. Clin Orthop Surg, 2021, 13(1): 47-52.
6. Tang SP, Wan KH, Lee RH, et al. Influence of hamstring autograft diameter on graft failure rate in Chinese population after anterior cruciate ligament reconstruction. Asia Pac J Sports Med Arthrosc Rehabil Technol, 2020, 22: 45-48.
7. Mariscalco MW, Flanigan DC, Mitchell J, et al. The influence of hamstring autograft size on patient-reported outcomes and risk of revision after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) Cohort Study. Arthroscopy, 2013, 29(12): 1948-1953.
8. van Eck CF, Schkrohowsky JG, Working ZM, et al. Prospective analysis of failure rate and predictors of failure after anatomic anterior cruciate ligament reconstruction with allograft. Am J Sports Med, 2012, 40(4): 800-807.
9. Conte EJ, Hyatt AE, Gatt CJ, et al. Hamstring autograft size can be predicted and is a potential risk factor for anterior cruciate ligament reconstruction failure. Arthroscopy, 2014, 30(7): 882-890.
10. Mueller MM, Rilk S, von Rehlingen-Prinz F, et al. Editorial commentary: Anterior cruciate ligament reconstruction or repair with suture augmentation allows early rehabilitation: collagen co-braid sutures may improve biological integration. Arthroscopy, 2024. doi: 10.1016/j.arthro.2024.10.022.
11. Wilson WT, Kennedy MJ, MacLeod D, et al. Outcomes of anterior cruciate ligament reconstruction with independently tensioned suture tape augmentation at 5-year follow-up. Am J Sports Med, 2023, 51(14): 3658-3664.
12. Alexeev SO, Buckley SE, Hewitt MA, et al. Publication trends in ligament augmentation techniques: current concepts. J ISAKOS, 2023, 8(4): 232-238.
13. Smith PA, Bley JA. Allograft anterior cruciate ligament reconstruction utilizing internal brace augmentation. Arthrosc Tech, 2016, 5(5): e1143-e1147.
14. McGee R, Daggett M, Jacks A, et al. Patellar tendon graft anterior cruciate ligament reconstruction technique with suture tape augmentation. Arthrosc Tech, 2019, 8(4): e355-e361.
15. Daniel AV, Smith PA. Primary all-soft tissue quadriceps tendon autograft anterior cruciate ligament reconstruction with suture tape augmentation resulted in satisfactory patient outcomes and a low graft failure rate in high school and collegiate athletes. Arthroscopy, 2025, 41(1): 95-105.
16. Smith PA, Bradley JP, Konicek J, et al. Independent suture tape internal brace reinforcement of bone-patellar tendon-bone allografts: biomechanical assessment in a full-ACL reconstruction laboratory model. J Knee Surg, 2020, 33(10): 1047-1054.
17. Daniel AV, Smith PA. Risk for revision ACLR after primary all-inside quadrupled semitendinosus hamstring tendon autograft ACLR with independent suture tape augmentation: a retrospective cohort study. Orthop J Sports Med, 2024, 12(9): 23259671241270308. doi: 10.1177/23259671241270308.
18. van Eck CF, Limpisvasti O, ElAttrache NS. Is there a role for internal bracing and repair of the anterior cruciate ligament? A systematic literature review. Am J Sports Med, 2018, 46(9): 2291-2298.
19. Smith JO, Yasen SK, Palmer HC, et al. Paediatric ACL repair reinforced with temporary internal bracing. Knee Surg Sports Traumatol Arthrosc, 2016, 24(6): 1845-1851.
20. Aboalata M, Elazab A, Halawa A, et al. Internal suture augmentation technique to protect the anterior cruciate ligament reconstruction graft. Arthrosc Tech, 2017, 6(5): e1633-e1638.
21. Beynnon BD, Johnson RJ, Fleming BC, et al. Anterior cruciate ligament replacement: comparison of bone-patellar tendon-bone grafts with two-strand hamstring grafts. A prospective, randomized study. J Bone Joint Surg (Am), 2002, 84(9): 1503-1513.
22. Grindem H, Engebretsen L, Axe M, et al. Activity and functional readiness, not age, are the critical factors for second anterior cruciate ligament injury-the Delaware-Oslo ACL cohort study. Br J Sports Med, 2020, 54(18): 1099-1102.
23. Raja BS, Arora M, Gowda AKS, et al. Augmentation with fibertape leads to biomechanically superior but similar clinical outcomes in ACL surgeries: systematic review and meta-analysis. Indian J Orthop, 2023, 57(5): 722-747.
24. Matava MJ, Koscso J, Melara L, et al. Suture tape augmentation improves the biomechanical performance of bone-patellar tendon-bone grafts used for anterior cruciate ligament reconstruction. Arthroscopy, 2021, 37(11): 3335-3343.
25. Wicks ED, Stack J, Rezaie N, et al. Biomechanical evaluation of suture tape internal brace reinforcement of soft tissue allografts for ACL reconstruction using a porcine model. Orthop J Sports Med, 2022, 10(5): 23259671221091252. doi: 10.1177/23259671221091252.
26. Wallace GJ, Thompson JD, Diekfuss JA, et al. Suture augmentation of a four-strand semitendinosus graft improves time-zero biomechanical properties. Arthroscopy, 2024, 40(1): 124-132.
27. Soreide E, Denbeigh JM, Lewallen EA, et al. In vivo assessment of high-molecular-weight polyethylene core suture tape for intra-articular ligament reconstruction: an animal study. Bone Joint J, 2019, 101-B(10): 1238-1247.
28. Lamplot JD, Smith BL, Slone HS, et al. Tape-reinforced graft suturing and retensioning of adjustable-loop cortical buttons improve quadriceps tendon autograft biomechanics in anterior cruciate ligament reconstruction: a cadaveric study. Arthroscopy, 2024, 40(1): 136-145.
29. Bachmaier S, Smith PA, Bley J, et al. Independent suture tape reinforcement of small and standard diameter grafts for anterior cruciate ligament reconstruction: a biomechanical full construct model. Arthroscopy, 2018, 34(2): 490-499.
30. Noonan BC, Bachmaier S, Wijdicks CA, et al. Independent suture tape reinforcement of tripled smaller-diameter and quadrupled grafts for anterior cruciate ligament reconstruction with tibial screw fixation: a biomechanical full construct model. Arthroscopy, 2020, 36(2): 481-489.
31. Murray MM, Fleming BC. Biology of anterior cruciate ligament injury and repair: Kappa delta ann doner vaughn award paper 2013. J Orthop Res, 2013, 31(10): 1501-1506.
32. Athiviraham A, Lee CS, Smith PA, et al. Self-tensioning feature of knotless suture anchor provides reproducible knotless fixation independent of initial tension. Orthop J Sports Med, 2021, 9(3): 2325967121991593. doi: 10.1177/2325967121991593.
33. Bodendorfer BM. Editorial commentary: the suture-augmented anterior cruciate ligament reconstruction requires independent tensioning to achieve load sharing. Arthroscopy, 2023, 39(4): 1025-1027.
34. Mackay GM, Wilson WT, Hopper GP. Editorial commentary: anterior cruciate ligament repair or reconstruction with internal bracing, for properly indicated patients, is safe, biocompatible, and biomimetic. Arthroscopy, 2024, 40(9): 2504-2506.
35. Smith PA. Editorial commentary: Anterior cruciate ligament graft reinforcement: a new era supported by science. Arthroscopy, 2019, 35(7): 2123-2126.
36. Claes S, Verdonk P, Forsyth R, et al. The "ligamentization" process in anterior cruciate ligament reconstruction: what happens to the human graft? A systematic review of the literature. Am J Sports Med, 2011, 39(11): 2476-2483.
37. Szakiel PM, Aksu NE, Kirloskar KM, et al. Rehabilitation and functional outcomes in internally braced and standard ACL reconstructions. J Orthop, 2022, 33: 95-99.
38. Amiel D, Kleiner JB, Roux RD, et al. The phenomenon of "ligamentization": anterior cruciate ligament reconstruction with autogenous patellar tendon. J Orthop Res, 1986, 4(2): 162-172.
39. Shino K, Inoue M, Horibe S, et al. Maturation of allograft tendons transplanted into the knee. An arthroscopic and histological study. J Bone Joint Surg (Br), 1988, 70(4): 556-560.
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