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Corresponding authorUniversity of Colorado School of Medicine Department of Orthopedic Surgery 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045 (303) 724-8936
Ligament augmentation techniques (LATs) are surgical procedures in which an anatomical ligament repair or reconstruction is strengthened with a synthetic material. During the last decade, LATs have increased in prevalence in clinical practice and academic literature. Observing trends in LAT publications can be used to identify clusters of strong evidence for clinical practice and highlight areas of the literature which need further development.
Objective
This article aims to define ligament augmentation as a technique category, observe anatomical, procedural, and temporal trends in LAT publication, and report on the state of current research in this field.
Evidence Review
Primary literature in the English language which describes ligament augmentation and reports on human, cadaveric, or biomechanical models, and published prior to May 24th, 2022, was targeted for analysis. PubMed, Embase, and Cochrane CENTER databases were explored using a focused keyword search strategy, and the resulting publications were reviewed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data was collected and analyzed using descriptive statistics.
Findings
283 publications reporting ligament augmentation techniques, published from May 1989 to May 2022, were included for final analysis. A wide technical and anatomical variety of procedures is reported. 36.8% of LAT publications describe knee ligaments, among which the ACL has the highest focus in ligament augmentation publications (31.8% of articles). LAT literature has recently expanded in anatomical scope, with many contemporary articles describing usage of LAT in the ankle syndesmosis and coracoclavicular ligaments. 60.4% of LAT literature has been published since 2017. There has been an 11% average increase in rate of LAT publication reports since 2015. Novel fixation devices - suture buttons and suture anchors - have gained wide popularity in the literature.
Conclusions and Relevance
In this review, we define ligament augmentation techniques and quantitatively describe the expansion of LAT use reported in the literature. This data will provide physicians an overview of the history of these methods, as well as illustrate the broad range of applications available for the use of LATs.
The library of ligament augmentation technique publications has grown tremendously over the past decade
•
Use has expanded to many different ligaments and anatomic regions
•
There is large diversity in the materials used in fixation and augmentation
•
The number of ligament augmentation publications numbers can be expected to grow further
Introduction
Untreated ligament tears can decrease stability of a joint and may lead to further damage of their surrounding structures, thereby leading to decreased quality of life as compared to reconstructed ligaments
. Ligament repairs and reconstruction are performed across orthopedic subspecialties with various degrees of success depending on the indication. While surgical repair of damaged ligaments tends to improve outcomes overall, a significant gap between pre-injury functional status and post-surgical repair may remain
Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors.
In pursuit of better outcomes, orthopedic surgeons have moved toward incorporating synthetic ligaments, or ligament augmentation devices, to provide additional stability to native tissues in ligament repair and reconstruction. Although “ligament augmentation” is a term with broad definitions in the literature, the general purpose of these techniques is to allow for stronger repairs and quicker return to activity
. In medical device sales, kits intended for ligament augmentation, consisting of the necessary fixation devices and synthetic ligament, are sometimes sold with unified branding and described as a solitary “technique” – this article aims to break this concept down into its discrete portions for clarity of analysis.
The authors define Ligament Augmentation Techniques (LATs) as techniques in which a ligament is repaired or reconstructed with a synthetic material which spans from bone to bone and is fixated intra- or trans-osseously, such as with a suture anchor, suture button, or interference screw. Synthetic ligaments can possibly avoid some of the postoperative complications associated with autograft and allograft transplantation,
and can be used as a supplement for allograft tissue. Synthetic ligaments do not lead to significant donor site morbidity, and avoid persistent pain and loss of flexibility, which are common complications of autograft use
Although ligament repair with synthetic protheses has been attempted for over a century, the modern history of LATs dates to the 1980s, when polymer devices such as polypropylene braid were first used in ACL reconstruction. Commercial ACL ligament augmentation devices were initially produced during this time, including the Kennedy LAD (3M, St. Paul, MN), and the Dacron graft (Stryker, Kalamazoo, MI)
. These first-generation devices are now less commonly used, which may be a result of relatively higher reported rates of complications with their use, such as infection, autoimmune reaction, and graft failure
. Current example techniques frequently use the Ligament Advanced Reinforcement System (LARS; LARS Company, Arc sur Tille, France), InternalBrace (Arthrex, Inc., Naples, FL, USA), and TightRope (Arthrex, Inc., Naples, FL, USA).
Historical reporting on LAT literature is important because this technique has had cyclical surges of popularity over time. In 1902, a German physician attempted an ultimately unsuccessful ACL reconstruction utilizing a combined silk fiber and semitendinosus graft
. Examining the previous reports on this topic can help researchers understand the pitfalls of historical attempts at LATs and give inspiration for techniques which could be used to strengthen patient outcomes.
We present this systematic review with the goal of elucidating the current publication trends in the orthopedic literature on LAT techniques, materials, and clinical outcomes. The authors hypothesized that the quantity of ligament augmentation reports would demonstrate tremendous growth in the period between 2010 and 2022. This hypothesis was influenced by the recent explosion of the usage of LATs in clinical practice. Indeed, 75.3% of ISAKOS member orthopedists surveyed in 2021 reported that they use the technique
ISAKOS LAF Committee Ligament Augmentation Repair is Broadly Applied Across Different Orthopedic Subspecialties: An ISAKOS International Survey of Orthopedic Surgeons [Manuscript submitted for publication].
The authors conducted a systematic review which utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. No ethics board approval was required for this study. A keyword-based literature search which combines a surgical term relevant to the topic of the review, such as “augmentation”, “internal brace”, or “suture tape”, and anatomical terms like “ATFL” or “ACL” was created. This search strategy was executed in the PubMed, EMBASE, and Cochrane CENTER databases, yielding results spanning from May 1989 to May 2022. The full search terms are available in appendix A1.
After duplicate publications were removed, the studies were screened by two independent reviewers, SA and SB, for inclusion. Titles and abstracts were screened in duplicate, and studies were included if they were 1) primary literature, 2) LATs were a subject of the report, 3) if they utilized human, cadaveric, or biomechanical models, and 4) if they were published in the English language. Publications utilizing animal models were excluded, as were systematic review articles. All articles in which there was a discrepancy in grading were evaluated for final inclusion by author MH. A full-text review of the articles was subsequently performed by SA. All relevant data was recorded from each full text for review. Principal summary measures include the year of publication, LAT device used, the ligament or anatomic region to which it was applied, fixation method, and the synthetic material applied. Data was evaluated using basic descriptive statistics.
Results
The results of our online literary database search and review are reported in the form of a PRISMA flow chart.
There were 1702 studies captured by our search of the PubMed, Embase, and Cochrane CENTER databases after removing duplicates. Title and abstract screening yielded 720 relevant reports, and 280 articles were included in our final analysis following full text review and application of the inclusion criteria (Fig. 1).
Although LATs are surgical techniques which have been reported in the literature as early as 1989, the majority of LAT papers have been published within the past 5 years. 60.4% of the publications captured by our search were published between 2017 and June 2022. This trend correlates to the invention and commercialization of devices such as the InternalBrace ™ and ZipTight ™ fixation systems, both patented in 2012 fig2A.
Figure 2ANumber of LAT publications per annum. Trends in LAT literature by anatomical region
The general anatomical breakdown of publications of which LATs are a focus is reported by year (Fig. 2B). Early utilization of ligament augmentation techniques was focused on the knee, particularly on the ACL, with first generation devices such as the Kennedy LAD
Comparison of patella tendon versus patella tendon/Kennedy ligament augmentation device for anterior cruciate ligament reconstruction: study of results, morbidity, and complications.
. Prior to 2005, 30 of 30 LAT publications report of the use of ligament augmentation in the ACL. Following 2005, foot and ankle literature describing usage of LATs increased following the development of techniques such as syndesmosis tightrope reconstruction and suture tape augmentation of the lateral ankle ligaments
Anterior talofibular ligament ruptures, part 1: biomechanical comparison of augmented Broström repair techniques with the intact anterior talofibular ligament.
. Increases in the shoulder body of literature are mostly related to the use of suture button constructs in reconstructing the coracoclavicular ligaments of the acromioclavicular joint
Comparison of patella tendon versus patella tendon/Kennedy ligament augmentation device for anterior cruciate ligament reconstruction: study of results, morbidity, and complications.
Comparison of patella tendon versus patella tendon/Kennedy ligament augmentation device for anterior cruciate ligament reconstruction: study of results, morbidity, and complications.
, the usage of suture button to suture button constructs has greatly increased in the literature (Fig. 3). Many anatomical areas of LAT usage now use suture button constructs, with 56.8% of articles from 2008 to 2022 detailing the use of at least one button in LAT fixation. This can partially be explained by the expansion of LATs in the acromioclavicular joint and ankle syndesmosis, where suture buttons are overwhelmingly used.
Figure 4 demonstrates the distribution of ligaments which are repaired or reconstructed in the publications included in the literature. Articles in which multiple ligaments are augmented with LATs are counted for all ligaments. In this figure, the broad nature of the usage of this technique in clinical practice is evident, and the adaptable nature of LATs are shown. However, it should be noted that the largest bodies of information in the literature describe the ACL, ankle syndesmosis, ATFL, and the AC joint, with 80% of 280 inclusions of ligament augmentation techniques being in these anatomical subsets. Numerous articles describe the use of LATs in multiple ligaments, such as the ACL and PCL concurrently
The 15 journals with the most publications on this topic are listed (Table 1). The highest number of LAT publications are in the Orthopedic Journal of Sports Medicine (24, 8.6%), American Journal of Sports Medicine (19, 6.8%), Foot & Ankle International (18, 6.4%) and Knee Surgery, Sports Traumatology, and Arthroscopy (16, 5.7%). Although it has been demonstrated that the number of ligament augmentation articles has greatly increased with time (fig. 2A), there is no correlation between self-reported level of evidence of articles included in this study and the year of publication (r2=.001).
Table 1Journals by LAT publication count
Title of Journal
Number of LAT Publications
Orthopedic Journal of Sports Medicine
24
American Journal of Sports Medicine
19
Foot and Ankle International
18
Knee Surgery, Sports Traumatology, and Arthroscopy
16
Foot and Ankle Surgery
15
Arthroscopy
10
Arthroscopy Techniques
9
Archives of Orthopedics and Trauma Surgery
9
Injury
7
Journal of Shoulder and Elbow Surgery
6
European Journal of Orthopedic Surgery and Traumatology
There are three primary fixation methods used in securing synthetic connecting materials to bone in LATs: interference screws, suture anchors, and suture buttons. We present a breakdown of the devices used for fixation and ligament repair [Table 2]. 70.3% of articles included in this systematic review stated the specific fixation devices used in the augmentation, and 79.3% listed the bridging material which was used. Some articles listed only the fixation devices, or the connecting material used in their technique. As demonstrated in Table 2, some ligament augmentation constructs use disparate types of devices at either end of their fixation, e.g., a suture button at one end and an interference screw at the other. Suture anchor to suture button constructs and suture button to interference screw concepts are described in the literature, but interestingly, to our knowledge, there is no literature which describes the usage of both a suture anchor and an interference screw in ligament augmentation fixation. Suture button to suture button fixation is the most common form of ligament augmentation, with over half of all included articles using this method. Ten articles captured describe ligament augmentation constructs which use staples as fixation devices for synthetic ligaments; these are excluded from this chart.
Table 2Branded ligament augmentation devices in literature
Analysis of LAT publications demonstrates that there have been increases in number of publications, anatomical scope, and diversity of materials used. Usage of the Dacron synthetic ligament to replace the anterior cruciate ligament by Lukianov et al. in 1989 was the first report of LAT
. Subsequently, the usage of synthetic materials, such as the Kennedy LAD, in ACL reconstruction was the only area of focus of LATs in the literature prior to 2005
Arthroscopic reconstruction of the anterior cruciate ligament using bone-patellar tendon-bone grafts with and without augmentation. A prospective randomised study.
Journal of bone and joint surgery British.1996; 78(Clinical Trial; Journal Article; Randomized Controlled Trial): 817-822
. Thornes et al. then reported on the use of suture button fixation in patients with syndesmotic injuries, leading to superior outcomes as compared to syndesmotic screw fixation
. Baumgarten et al. reported the first use of ligament augmentation reconstruction of the acromioclavicular joint by using a dual suture button construct in 2008
. This period of literature was a germination point for the spread of this technique to other ligaments, resulting in the diverse distribution of reports currently available [fig. 4]. In the past decade, the repository of LAT literature has expanded almost exponentially, and futher year-to-year growth in publication numbers can be anticipated. Additionally, this technique has reached wide popularity, with a plurality of orthopedic surgeons surveyed in 2021 using LATs in their practice
ISAKOS LAF Committee Ligament Augmentation Repair is Broadly Applied Across Different Orthopedic Subspecialties: An ISAKOS International Survey of Orthopedic Surgeons [Manuscript submitted for publication].
Devices are central to the concept of LATs and it is important to recognize the historical trends of device use when considering synthetic augmentation. First generation ligament augmentation devices, such as the Kennedy LAD, are generally not used in the present day, partially because of poor outcomes associated with their implantation
. These devices differ from the modern constructs in significant ways. Firstly, these historical devices were typically fixed to bone through the usage of relatively large titanium interference screws, as compared to modern bioabsorable anchors and minimally invasive suture buttons. Secondly, the assembly of the suture materials used in LATs has evolved over time. Although all devices listed in this study use similar polymers for the braided suture involved in tensioning, typically high density polyethylene or polypropylene, the construction of suture materials such as FiberWire and FiberTape is two-layered, with an inner core and and outer sheath, whereas the Kennedy LAD is one-layered.
One striking detail reported in this review is the expansion of suture button fixation over time. The greater adoption of these fixation methods could be related to the expansion in anatomical scope of LATs – as the number of papers which examine LATs in ligaments which are best repaired through this fixation method increases, the number of papers using them will increase as well. In addition to this consideration, there are clear indications for the use of suture button fixation methods in specific situations – for example, double TightRope fixation has been demonstrated to be stronger than anchor to button fixation in the setting of AC joint reduction
. Few studies compare the the benefits of any type of ligament augmentation fixation over another, and this area of technique literature may be a fruitful area of future investigation. In using suture button fixation, physicians should consider the possibility of button migration, loss of reduction, infection, and osteomyelitis as possible complications in choosing whether to pursue suture button fixation over other methods
Another interesting finding is the near linear increase in publications since 2005 in all relevant subsepcialty areas. The first usage of LAT devices outside of the knee was in 2005, in usage for reduction of the ankle syndemsosis. This was followed by significant increases in technique and clinical papers describing LATs in the foot and ankle, followed by a resurgence in the knee, shoulder, and eventually the hand and wrist around 2013. This correlates well with our survey data which indicated that the majority of foot and ankle, knee, and shoulder surgeons surveyed use LATs, and that just under 50% of hand surgeons utilize LATs
ISAKOS LAF Committee Ligament Augmentation Repair is Broadly Applied Across Different Orthopedic Subspecialties: An ISAKOS International Survey of Orthopedic Surgeons [Manuscript submitted for publication].
Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors.
ACL Reconstruction Using Autologous Hamstrings Augmented With the Ligament Augmentation and Reconstruction System Provides Good Clinical Scores, High Levels of Satisfaction and Return to Sport, and a Low Retear Rate at 2 Years.
. To date, there is no high level evidence to support more aggressive rehabilitation techniques with use of LATs. However, given the surge in use, volumes, and literature, such comparisons and guidelines are inevitably forthcoming.
Although modern LAT devices have not had as many reports of synovitis and adverse reactions, physicians should be vigilant in recognizing these issues due to the relative similarities between these synthetic grafts and those which have previously caused pathology in patients. This is especially important to consider in the longitudinal evaluation of the safety of new generation devices because severe complications, such as synovitis, in devices like the LARS ligament have been observed many years after implantation
. Recent attempts to achieve further biocompatibility, and thereby reduce reactivity, have involved the use of collagen-coated suture material in order to reduce complications
. Research in creating more biocompatible ligament augmentation devices is ongoing – innovation in these devices could eventually avoid acute and chronic immunologic reactions and confer less chance for postoperative infection as compared to allograft ligament transplantation, although such advancements have not been demonstrated thus far
. Further development of the materials involved in LATs may lead to fewer instances of adverse outcomes and improved healing.
In conducting this current concept review, we encountered multiple challenges and thus faced certain limitations. Numerous articles in this sector of the orthopedic literature describe ligament augmentation techniques, but do not provide sufficient reporting of the materials and methods used in their procedures, and thus these variables could not be collected for data analysis. Our study lacks coverage of the orthopedic literature outside of the English language. Because this review aimed to describe the trends in these technique relating to human subjects, veterinary literature, and literature which attempted to model human anatomy through the use of animal models, was not considered for inclusion. Additionally, certain articles were unable to be accessed due to paywalls and lack of open-access. Moreover, our review only considers reports archived in major literature databases – PubMed, EMBASE, and Cochrane CENTER – and thereby excludes publications in journals which are not indexed in these services.
Conclusion
This systematic review clarifies the term ligament augmentation techniques and describes the growth of this up-and-coming topic in the orthopedic surgical literature over time. Based on previous trends, we can expect ligament augmentation techniques to become more prevalent in orthopedic publication, as well as in clinical practice, in the future. This trend can be explained by innovation in materials and methods used in these techniques, as well as through the clinical outcomes demonstrated by several landmark publications. Research providing clarity on the longitudinal effectiveness of ligament augmentation techniques would improve the body of literature.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of interests
☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
(“augmentation”[tw] OR "internal brac*"[tw] OR "suture tape"[tw] OR “suture-tape”[tw] OR “reinforcement”[tw] OR “suture button”[tw] OR “suture-button”[tw] OR “tightrope”[tw] OR “internalbrace”[tw] OR “fiberwire”[tw]) AND (“ATFL”[tw] OR “Anterior Talofibular”[tw] OR “Brostrom”[tw] OR “Achilles”[tw] OR “Calcaneal”[tw] OR “Calcaneofibular”[tw] OR “CFL”[tw] OR “Deltoid”[tw] OR “Spring”[tw] OR “Calcaneonavicular”[tw] OR “Plantar calcaneonavicular”[tw] OR “Anterior inferior tibiofibular”[tw] OR “Anterior tibiofibular”[tw] OR “AITFL”[tw] OR “Liscfranc”[tw] OR “Tarsometatarsal”[tw] OR “Peroneal”[tw] OR “Peroneus”[tw] OR “Fibularis brevis”[tw] OR “Fibularis longus”[tw] OR “interosseus”[tw] OR “syndesmosis”[tw] OR “syndesmotic”[tw] OR “total talus”[tw] OR “hallux”[tw] OR “Acromioclavicular”[tw] OR “AC”[tw] OR “Rotator cuff”[tw] OR “sternoclavicular”[tw] OR “SC”[tw] OR “SCJ”[tw] OR “coracoclavicular”[tw] OR “Lateral ulnar collateral”[tw] OR “LUCL”[tw] OR “Ulnar collateral”[tw] OR “UCL”[tw] OR “Ulnar”[tw] OR “Triangular fibrocartilage”[tw] OR “Scapholunate”[tw] OR “Carpometacarpal”[tw] OR “CMC”[tw] OR “Annular”[tw] OR “RCL” [tw] OR “medial epicondyle”[tw] OR “ACL”[tw] OR “anterior cruciate”[tw] OR “PCL”[tw] OR “Posterior cruciate” OR “MCL”[tw] OR “Medial collateral”[tw] OR “LCL”[tw] OR “lateral collateral”[tw] OR “popliteofibular”[tw] OR “popliteal”[tw] OR “patellar”[tw] OR “quadriceps tendon”[tw] OR “patellofemoral”[tw] OR “anterolateral”[tw] OR “posteromedial”[tw])
References
Hawkins R.J.
Misamore G.W.
Merritt T.R.
Followup of the acute nonoperated isolated anterior cruciate ligament tear.
Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors.
Ligament Augmentation Repair is Broadly Applied Across Different Orthopedic Subspecialties: An ISAKOS International Survey of Orthopedic Surgeons [Manuscript submitted for publication].
Anterior talofibular ligament ruptures, part 1: biomechanical comparison of augmented Broström repair techniques with the intact anterior talofibular ligament.
Comparison of patella tendon versus patella tendon/Kennedy ligament augmentation device for anterior cruciate ligament reconstruction: study of results, morbidity, and complications.
Arthroscopic reconstruction of the anterior cruciate ligament using bone-patellar tendon-bone grafts with and without augmentation. A prospective randomised study.
Journal of bone and joint surgery British.1996; 78(Clinical Trial; Journal Article; Randomized Controlled Trial): 817-822
ACL Reconstruction Using Autologous Hamstrings Augmented With the Ligament Augmentation and Reconstruction System Provides Good Clinical Scores, High Levels of Satisfaction and Return to Sport, and a Low Retear Rate at 2 Years.
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