Assessment #2

Review of Four New Techniques in Primary Anterior Cruciate Ligament Repair.

Vedika Bakre

ISM I

Mr. Walters

Sept. 13, 2018

Mahalias M, Chytas D, Nakamura K, Raoulis V, Yokota M, Nikolaou V. “A Narrative Review of Four

New Techniques in Primary Anterior Cruciate Ligament Repair: ‘Back to the Future’ or Another

Trend?” Sports Medicine- Open. 2018. Cited 2018 Sept 13; 4:37. Pages 1-12. Available from:

https://doi.org/10.1186/s40798-018-0145-0

Most athletes are familiar with one specific ligament in the knee, the ACL. Studies even show

that, after ankle fractures, Anterior Cruciate Ligament surgeries are the second most common surgery

practiced by surgeons. However, there is a controversy concerning the optimal management of ACL

ruptures and several cases of inadequate recovery have been reported. In addition, ACL tears increase the

chances for a patient to develop osteoarthritis.

As many know, stem cell research and self-healing are topics that have recently been booming in

popularity in both the bioengineering and medical fields due to their decreased risks of rejection and

faster healing time. By the time I start practicing in the field, stem cells will be covered by insurance,

making them less costly, and they will be FDA-approved meaning that the technology required to harvest

the cells will be more readily available and again, less expensive. This article is comparing four types of

reconstruction surgery in order to see which one results in the most effective way to perform an ACL

reconstruction surgery with the least chance of failure.

 The first method, called Dynamic Intraligamentary Stabilization (DIS), is to insert a threaded

sleeve from the anteromedial portion of the tibia (the front of the shin, but a little bit to the inside). The

sleeve will have a preloaded spring attached and a mechanism for stabilizing. Instead of using a allograft

or autograft, a braided wire is passes through the middle of the torn ACL and is attached to the lateral

surface of the femur. Researchers noticed that the DIS promotes self healing which shows superior

outcomes in the case of ACL reconstruction. What I like about this procedure is that it is minimally

invasive and can be done without the use of any other muscle helping it. Even though I’m not fully

educated in the field, I know that minimally invasive techniques are also highly favored by patients

because of the decreased levels of pain and decreased recovery time.

Secondly, the author writes about a Bridge-Enhanced ACL Repair (BEAR). The procedure

involves vicryl sutures placed on the tibial end of the ACL and passes through a drilled femoral tunnel. It

was found that the BEAR procedure did not cause complications such as deep joint infection or

significant inflammation. While this procedure has good results, I don’t know how well this could work

on younger growing kids because it drills through the growth plate in one leg. From personal experience,

when I got my ACL surgery at age 14, nobody thought that I was going to grow anymore, so I ended up

getting a surgery that drilled a hole in my growth plate and prevented me from growing anymore- on the

side that I got surgery on. Approximately a year and a half later, I’m still having knee problems associated

with my hip levels because of a slight imbalance in height on my right and left side. Even though I don’t

know many of the technicalities associated with the field, I’m guessing that this procedure would work

very well on active adults due to them not being able to grow anymore and the minimally-invasive, low

recovery time nature of the BEAR.

The third procedure described is an Internal Brace. With this procedure, surgeons put a braided

suture through the proximal end of the braided suture, and the brace is pulled up through a drilled tibial

tunnel and up into the femoral tunnel. Something I found fascinating about this technique is that the
internal brace is actually removed after 3 months and that the screw is a bioabsorbable. Recently, I had to

get another MRI for my knee and the doctor found that one of the screws is actually poking out a couple

millimeters and he doesn’t know whether the screw was initially like that or whether it moved outwards.

In addition, I have a lot of scar tissue in my knee which causes contractures in my leg when I sit down for

a long time or after I get up from bed in the morning. In my opinion, I feel that a bioabsorbable screw and

a removal internal brace could decrease the chances of post-op complications.

Finally, the last technique that the author mentions is a Anchors Primary ACL Repair which

consists of a twist-in cannula placed into the anteromedial portal and a curved right angle lasso is passed

through the proximal end of the torn ACL. Finally, a wire is passed through a wire loop and inserted

through the anterolateral portal. The only drilling that happens in this type of surgery is a hole into the

bone to place an anchor to keep everything together. Research has found that using the anchor technique

could be successful in patients with excellent tissue quality and proximal avulsion (torn at tibia) ACL

ruptures. I think this technique could be highly effective for younger people because of the only holes

being in the bone and not through a growth plate and because younger people tend to have healthier tissue

than older people.

Before reading this article, I just assumed that all basic ACL surgeries happen the same way with

the surgeon removing the torn tissue and going in with either an allograft or an autograft to connect

everything back together again. Instead of one common method with a few tweaks depending on they

type of graft, there are techniques that don’t resemble each other at all. In addition, I learned about

reconstructive surgery, which is currently the gold standard, but can come with drawback such as

shortness in range of motion, knee pain, muscle atrophy, or infection. One more thing I learned a lot more

about from this article was self-healing. I never thought that ACL’s could be self-healing because people

that I know personally have gone 20-30 years without getting surgery to repair their torn ACL. I knew

that this was because they had no use for a ligament that technically isn’t in use unless you are making
sharp turns and/or pivoting. Because of this, I didn’t realize that an ACL could actually heal itself over

time. This article allowed me to connect my own experiences to actual scientific data that was easily

understandable.