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Suture Augmentation in Orthopaedic Surgery Offers Improved Time-Zero Biomechanics and Promising Short-Term Clinical Outcomes

Published:January 17, 2023DOI:https://doi.org/10.1016/j.arthro.2023.01.012

      Abstract

      Ligament and tendon ruptures have historically been addressed with varying techniques involving either repair or reconstruction. More recently, the potential biomechanical benefits of suture augmentation (SA), also known as internal brace, have attracted substantial attention and helped renew interest in ligament repair surgery. We evaluated the biomechanical and clinical outcomes of SA-based techniques in the following sports medicine procedures: medial ulnar collateral ligament repair of the elbow, thumb collateral ligament repair, anterior cruciate ligament repair, Achilles’ tendon repair, and deltoid ligament repair. Published data on the use of SA to augment repairs of the ulnar collateral ligament, thumb collateral ligament, anterior cruciate ligament, Achilles’ tendon, and deltoid ligament repair demonstrates improved time-zero biomechanical and promising short to mid-term clinical outcomes. However, surgeons must be wary of potential complications, including joint over-constraint, nerve paresthesia, and infection.
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      References

        • Siegel L.
        • Vandenakker-Albanese C.
        • Siegel D.
        Anterior cruciate ligament injuries: anatomy, physiology, biomechanics, and management.
        Clin J Sport Med. 2012; 22: 349-355
        • Leong N.L.
        • Kator J.L.
        • Clemens T.L.
        • James A.
        • Enamoto-Iwamoto M.
        • Jiang J.
        Tendon and Ligament Healing and Current Approaches to Tendon and Ligament Regeneration.
        J Orthop Res. 2020; 38: 7-12
        • Zaffagnini S.
        • Bruni D.
        • Russo A.
        • et al.
        ST/G ACL reconstruction: double strand plus extra-articular sling vs double bundle, randomized study at 3-year follow-up.
        Scand J Med Sci Sports. 2008; 18: 573-581
        • Wilson W.T.
        • Hopper G.P.
        • Byrne P.A.
        • MacKay G.M.
        Anterior Cruciate Ligament Repair with Internal Brace Ligament Augmentation.
        Surg Technol Int. 2016; 29: 273-278
        • Anvari A.
        • Fathi A.
        • Bolia I.K.
        • et al.
        Utilization of Internal Bracing in Elbow Medial UCL Stabilization: From Biomechanics to Clinical Application and Patient Outcomes.
        Orthop Res Rev. 2021; 13: 201-208
        • Fukuda A.
        • Nakazora S.
        • Nishimura A.
        • Kato K.
        Repair of Acute Patellar Tendon Rupture Using an Internal Brace Technique.
        Case Rep Orthop. 2021; 20211086625
        • Trasolini N.A.
        • Hatch G.F.
        • Wright D.
        • et al.
        Posterior Cruciate Ligament Reconstruction With Internal Brace Augmentation Reduces Posterior Tibial Translation Under Cyclic Loading.
        Orthopedics. 2021; 44: 235-240
        • Regauer M.
        • Mackay G.
        • Lange M.
        • Kammerlander C.
        • Böcker W.
        Syndesmotic. World J Orthop. 2017; 8: 301-309
        • Vermeijden H.D.
        • van der List J.P.
        • DiFelice G.S.
        Primary Repair of the Lateral Collateral Ligament Using Additional Suture Augmentation.
        Arthrosc Tech. 2020; 9: e1073-e1077
        • Dabis J.
        • Wilson A.
        Repair and Augmentation with Internal Brace in the Multiligament Injured Knee.
        Clin Sports Med. 2019; 38: 275-283
        • Rothermich M.A.
        • Fleisig G.S.
        • Lucas H.E.
        • et al.
        Early Complications of Ulnar Collateral Ligament Repair With Collagen-Coated Suture Tape Augmentation.
        Orthop J Sports Med. 2021; 923259671211038320
        • Nguyen D.M.
        • Murawski C.D.
        • Fu F.H.
        • Kaufmann R.A.
        Stress Shielding of Ligaments Using Nonabsorbable Suture Augmentation May Influence the Biology of Ligament Healing.
        J Hand Surg Am. 2022; 47: 275-278
        • Erickson B.J.
        • Chalmers P.N.
        • Bush-Joseph C.A.
        • Verma N.N.
        • Romeo A.A.
        Ulnar Collateral Ligament Reconstruction of the Elbow: A Systematic Review of the Literature.
        Orthop J Sports Med. 2015; 32325967115618914
        • Conte S.A.
        • Fleisig G.S.
        • Dines J.S.
        • et al.
        Prevalence of Ulnar Collateral Ligament Surgery in Professional Baseball Players.
        Am J Sports Med. 2015; 43: 1764-1769
        • Leland D.P.
        • Conte S.
        • Flynn N.
        • et al.
        Prevalence of Medial Ulnar Collateral Ligament Surgery in 6135 Current Professional Baseball Players: A 2018 Update.
        Orthop J Sports Med. 2019; 72325967119871442
        • Dugas J.R.
        • Walters B.L.
        • Beason D.P.
        • Fleisig G.S.
        • Chronister J.E.
        Biomechanical Comparison of Ulnar Collateral Ligament Repair With Internal Bracing Versus Modified Jobe Reconstruction.
        Am J Sports Med. 2016; 44: 735-741
        • Wilk K.E.
        • Arrigo C.A.
        • Bagwell M.S.
        • Rothermich M.A.
        • Dugas J.R.
        Repair of the Ulnar Collateral Ligament of the Elbow: Rehabilitation Following Internal Brace Surgery.
        J Orthop Sports Phys Ther. 2019; 49: 253-261
        • Bernholt D.L.
        • Lake S.P.
        • Castile R.M.
        • Papangelou C.
        • Hauck O.
        • Smith M.V.
        Biomechanical comparison of docking ulnar collateral ligament reconstruction with and without an internal brace.
        J Shoulder Elbow Surg. 2019; 28: 2247-2252
        • O'Connell R.
        • Hoof M.
        • Heffernan J.
        • O'Brien M.
        • Savoie F.
        Medial Ulnar Collateral Ligament Repair With Internal Brace Augmentation: Results in 40 Consecutive Patients.
        Orthop J Sports Med. 2021; 923259671211014230
        • Dugas J.R.
        • Looze C.A.
        • Capogna B.
        • et al.
        Ulnar Collateral Ligament Repair With Collagen-Dipped FiberTape Augmentation in Overhead-Throwing Athletes.
        Am J Sports Med. 2019; 47: 1096-1102
        • Urch E.
        • DeGiacomo A.
        • Photopoulos C.D.
        • Limpisvasti O.
        • ElAttrache N.S.
        Ulnar Collateral Ligament Repair With Suture Bridge Augmentation.
        Arthrosc Tech. 2018; 7: e219-e223
        • Jones C.M.
        • Beason D.P.
        • Dugas J.R.
        Ulnar Collateral Ligament Reconstruction Versus Repair With Internal Bracing: Comparison of Cyclic Fatigue Mechanics.
        Orthop J Sports Med. 2018; 62325967118755991
        • Bachmaier S.
        • Wijdicks C.A.
        • Verma N.N.
        • Higgins L.D.
        • Greiner S.
        Biomechanical Functional Elbow Restoration of Acute Ulnar Collateral Ligament Tears: The Role of Internal Bracing on Gap Formation and Repair Stabilization.
        Am J Sports Med. 2020; 48: 1884-1892
        • Glogovac G.
        • Kakazu R.
        • Aretakis A.C.
        • Grawe B.M.
        Return to Sport and Sports-Specific Outcomes Following Ulnar Collateral Ligament Reconstruction in Adolescent Athletes: A Systematic Review.
        HSS J. 2020; 16: 242-249
      1. Dugas J, Looze C, Jones C, et al. Ulnar Collateral Ligament Repair with Internal Brace Augmentation in Amateur Overhead Throwing Athletes. Vol 6. The Orthopaedic Journal of Sports Medicine2018:1.

        • Avery D.M.
        • Caggiano N.M.
        • Matullo K.S.
        Ulnar collateral ligament injuries of the thumb: a comprehensive review.
        Orthop Clin North Am. 2015; 46: 281-292
        • Chuter G.S.
        • Muwanga C.L.
        • Irwin L.R.
        Ulnar collateral ligament injuries of the thumb: 10 years of surgical experience.
        Injury. 2009; 40: 652-656
        • Jack R.A.
        • Sochacki K.R.
        • Gagliano B.
        • Lintner D.M.
        • Harris J.D.
        • McCulloch P.C.
        Performance and Return to Sport After Thumb Ulnar Collateral Ligament Repair in Major League Baseball Players.
        Orthop J Sports Med. 2018; 62325967117747268
        • Buchhorn T.
        • Sabeti-Aschraf M.
        • Dlaska C.E.
        • Wenzel F.
        • Graf A.
        • Ziai P.
        Combined medial and lateral anatomic ligament reconstruction for chronic rotational instability of the ankle.
        Foot Ankle Int. 2011; 32: 1122-1126
        • Dar Q.A.
        • Avoricani A.
        • Hayes W.T.
        • Levy K.H.
        • Wang H.
        • Koehler S.M.
        Biomechanical Comparison of 3 Thumb Ulnar Collateral Ligament Repair Methods.
        J Hand Surg Am. 2021;
        • Shin S.S.
        • van Eck C.F.
        • Uquillas C.
        Suture Tape Augmentation of the Thumb Ulnar Collateral Ligament Repair: A Biomechanical Study.
        J Hand Surg Am. 2018; 43: 868.e861-868.e866
        • Lee S.J.
        • Rabinovich R.V.
        • Kim A.
        Thumb Ulnar Collateral Ligament Repair with Suture Tape Augmentation.
        J Hand Surg Asian Pac. 2020; 25: 32-38
        • Gibbs D.B.
        • Shin S.S.
        Return to Play in Athletes After Thumb Ulnar Collateral Ligament Repair With Suture Tape Augmentation.
        Orthop J Sports Med. 2020; 82325967120935063
        • Samora J.B.
        • Harris J.D.
        • Griesser M.J.
        • Ruff M.E.
        • Awan H.M.
        Outcomes after injury to the thumb ulnar collateral ligament--a systematic review.
        Clin J Sport Med. 2013; 23: 247-254
        • Patel S.S.
        • Hachadorian M.
        • Gordon A.
        • Nydick J.
        • Garcia M.
        Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament: Early Outcomes of Suture Anchor Repair with Suture Tape Augmentation.
        J Hand Microsurg. 2022; 14: 25-30
        • Delma S.
        • Ozdag Y.
        • Baylor J.L.
        • Grandizio L.C.
        • Klena J.C.
        A Comparison of Acute Versus Chronic Thumb Ulnar Collateral Ligament Surgery Using Primary Suture Anchor Repair and Local Soft Tissue Advancement.
        J Hand Surg Glob Online. 2022; 4: 141-146
        • Wilson W.T.
        • Hopper G.P.
        • Banger M.S.
        • Blyth M.J.G.
        • Riches P.E.
        • MacKay G.M.
        Anterior cruciate ligament repair with internal brace augmentation: A systematic review.
        Knee. 2022; 35: 192-200
        • Samitier G.
        • Alentorn-Geli E.
        • Taylor D.C.
        • et al.
        Meniscal allograft transplantation. Part 2: systematic review of transplant timing, outcomes, return to competition, associated procedures, and prevention of osteoarthritis.
        Knee Surg Sports Traumatol Arthrosc. 2015; 23: 323-333
        • Takeuchi S.
        • Rothrauff B.B.
        • Kanto R.
        • Onishi K.
        • Fu F.H.
        Superb microvascular imaging (SMI) detects increased vascularity of the torn anterior cruciate ligament.
        Knee Surg Sports Traumatol Arthrosc. 2022; 30: 93-101
        • Murray M.M.
        Current status and potential of primary ACL repair.
        Clin Sports Med. 2009; 28: 51-61
        • Mackay G.M.
        • Blyth M.J.
        • Anthony I.
        • Hopper G.P.
        • Ribbans W.J.
        A review of ligament augmentation with the InternalBrace™: the surgical principle is described for the lateral ankle ligament and ACL repair in particular, and a comprehensive review of other surgical applications and techniques is presented.
        Surg Technol Int. 2015; 26: 239-255
        • Hoogeslag R.A.G.
        • Brouwer R.W.
        • Huis In 't Veld R.
        • Amis A.A.
        Isometric placement of the augmentation braid is not attained reliably in contemporary ACL suture repair.
        Knee. 2020; 27: 111-123
        • Bachmaier S.
        • DiFelice G.S.
        • Sonnery-Cottet B.
        • et al.
        Treatment of Acute Proximal Anterior Cruciate Ligament Tears-Part 2: The Role of Internal Bracing on Gap Formation and Stabilization of Repair Techniques.
        Orthop J Sports Med. 2020; 82325967119897423
        • Massey P.
        • Parker D.
        • McClary K.
        • Robinson J.
        • Barton R.S.
        • Solitro G.F.
        Biomechanical comparison of anterior cruciate ligament repair with internal brace augmentation versus anterior cruciate ligament repair without augmentation.
        Clin Biomech (Bristol, Avon). 2020; 77105065
        • Häberli J.
        • Voumard B.
        • Kösters C.
        • et al.
        Implant preloading in extension reduces spring length change in dynamic intraligamentary stabilization: a biomechanical study on passive kinematics of the knee.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 3582-3592
        • Burton D.A.
        • Schaefer E.J.
        • Shu H.T.
        • Bodendorfer B.M.
        • Argintar E.H.
        Primary Anterior Cruciate Ligament Repair Using Suture Tape Augmentation: A Case Series of 29 Patients With Minimum 2-Year Follow-Up.
        Arthroscopy. 2021; 37: 1235-1241
        • Douoguih W.A.
        • Zade R.T.
        • Bodendorfer B.M.
        • Siddiqui Y.
        • Lincoln A.E.
        Anterior Cruciate Ligament Repair with Suture Augmentation for Proximal Avulsion Injuries.
        Arthrosc Sports Med Rehabil. 2020; 2: e475-e480
        • Gagliardi A.G.
        • Carry P.M.
        • Parikh H.B.
        • Traver J.L.
        • Howell D.R.
        • Albright J.C.
        ACL Repair With Suture Ligament Augmentation Is Associated With a High Failure Rate Among Adolescent Patients.
        Am J Sports Med. 2019; 47: 560-566
        • Heusdens C.H.W.
        • Blockhuys K.
        • Roelant E.
        • Dossche L.
        • Van Glabbeek F.
        • Van Dyck P.
        Suture tape augmentation ACL repair, stable knee, and favorable PROMs, but a re-rupture rate of 11% within 2 years.
        Knee Surg Sports Traumatol Arthrosc. 2021; 29: 3706-3714
        • Dabis J.
        • Yasen S.K.
        • Foster A.J.
        • Pace J.L.
        • Wilson A.J.
        Paediatric proximal ACL tears managed with direct ACL repair is safe, effective and has excellent short-term outcomes.
        Knee Surg Sports Traumatol Arthrosc. 2020; 28: 2551-2556
        • Smith J.O.
        • Yasen S.K.
        • Palmer H.C.
        • Lord B.R.
        • Britton E.M.
        • Wilson A.J.
        Paediatric ACL repair reinforced with temporary internal bracing.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 1845-1851
        • Muller B.
        • Yabroudi M.A.
        • Lynch A.
        • et al.
        Defining Thresholds for the Patient Acceptable Symptom State for the IKDC Subjective Knee Form and KOOS for Patients Who Underwent ACL Reconstruction.
        Am J Sports Med. 2016; 44: 2820-2826
        • Ortmaier R.
        • Fink C.
        • Schobersberger W.
        • et al.
        Return to Sports after Anterior Cruciate Ligament Injury: a Matched-Pair Analysis of Repair with Internal Brace and Reconstruction Using Hamstring or Quadriceps Tendons.
        Sportverletz Sportschaden. 2021; 35: 36-44
        • Schneider K.N.
        • Schliemann B.
        • Gosheger G.
        • et al.
        Good to Excellent Functional Short-Term Outcome and Low Revision Rates Following Primary Anterior Cruciate Ligament Repair Using Suture Augmentation.
        J Clin Med. 2020; 9
        • van Eck C.F.
        • Limpisvasti O.
        • ElAttrache N.S.
        Is There a Role for Internal Bracing and Repair of the Anterior Cruciate Ligament? A Systematic Literature Review.
        Am J Sports Med. 2018; 46: 2291-2298
        • Delincé P.
        • Ghafil D.
        Anterior cruciate ligament tears: conservative or surgical treatment? A critical review of the literature.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 48-61
        • Hopper G.P.
        • Heusdens C.H.W.
        • Dossche L.
        • Mackay G.M.
        Posterolateral Corner Repair With Suture Tape Augmentation.
        Arthrosc Tech. 2018; 7: e1299-e1303
        • van Eck C.F.
        • Nakamura T.
        • Price T.
        • Linde M.
        • Smolinski P.
        Suture tape augmentation improves laxity of MCL repair in the ACL reconstructed knee.
        Knee Surg Sports Traumatol Arthrosc. 2021; 29: 2545-2552
        • Gilmer B.B.
        • Crall T.
        • DeLong J.
        • Kubo T.
        • Mackay G.
        • Jani S.S.
        Biomechanical Analysis of Internal Bracing for Treatment of Medial Knee Injuries.
        Orthopedics. 2016; 39: e532-537
        • Grotting J.A.
        • Nelson T.J.
        • Banffy M.B.
        • et al.
        Biomechanical evaluation of PCL reconstruction with suture augmentation.
        Knee. 2020; 27: 375-383
        • Ostrander R.
        • Jordan S.
        • Konicek J.
        • Baldwin W.
        Suture Tape-Augmented Posterior Cruciate Ligament Repair Should Be Tensioned and Fixed at Approximately 100° Knee Flexion to Prevent Loss of Full Flexion.
        Arthrosc Sports Med Rehabil. 2021; 3: e1811-e1818
        • Hopper G.P.
        • Irfan A.
        • Jenkins J.M.
        • Wilson W.T.
        • Mackay G.M.
        Posterior cruciate ligament repair with suture tape augmentation: a case series with minimum 2-year follow-up.
        J Exp Orthop. 2021; 8: 28
        • Ko P.Y.
        • Huang M.T.
        • Li C.L.
        • Su W.R.
        • Jou I.M.
        • Wu P.T.
        Jigless knotless internal brace technique for acute Achilles tendon rupture: a case series study.
        J Orthop Surg Res. 2019; 14: 415
        • McWilliam J.R.
        • Mackay G.
        The Internal Brace for Midsubstance Achilles Ruptures.
        Foot Ankle Int. 2016; 37: 794-800
        • Ko P.Y.
        • Hsu C.H.
        • Hong C.K.
        • et al.
        Jigless knotless internal brace versus other open Achilles tendon repairs using a progressive rehabilitation protocol: a biomechanical study.
        BMC Musculoskelet Disord. 2021; 22: 908
        • Chida S.
        • Suzuki H.
        • Kobayashi M.
        • et al.
        Reconstruction of a chronically ruptured Achilles tendon using an internal brace: a case report.
        J Med Case Rep. 2018; 12: 54
        • Stavenuiter X.J.R.
        • Lubberts B.
        • Prince R.M.
        • Johnson A.H.
        • DiGiovanni C.W.
        • Guss D.
        Postoperative Complications Following Repair of Acute Achilles Tendon Rupture.
        Foot Ankle Int. 2019; 40: 679-686
        • McMahon S.E.
        • Smith T.O.
        • Hing C.B.
        A meta-analysis of randomised controlled trials comparing conventional to minimally invasive approaches for repair of an Achilles tendon rupture.
        Foot Ankle Surg. 2011; 17: 211-217
        • Pellegrini M.J.
        • Torres N.
        • Cuchacovich N.R.
        • Huertas P.
        • Muñoz G.
        • Carcuro G.M.
        Chronic deltoid ligament insufficiency repair with Internal Brace™ augmentation.
        Foot Ankle Surg. 2019; 25: 812-818
        • Hintermann B.
        • Valderrabano V.
        • Boss A.
        • Trouillier H.H.
        • Dick W.
        Medial ankle instability: an exploratory, prospective study of fifty-two cases.
        Am J Sports Med. 2004; 32: 183-190
        • Pellegrini M.J.
        • Carcuro G.
        Chronic deltoid ligament insufficiency repair with Internal Brace™ augmentation.
        Foot Ankle Surg. 2020; 26: 835