Failure Rates After Anterior Cruciate Ligament Repair With Suture Tape Augmentation in an Active-Duty Military Population

Abstract

Background: Anterior cruciate ligament (ACL) repair had previously been considered the standard of care for a ruptured ACL; however, ACL reconstruction has became the standard of care because of poor midterm outcomes after ACL repair. Recently, studies have suggested that the treatment paradigm should shift back to ACL repair. Purpose/Hypothesis: The purpose of this study was to evaluate the outcomes of ACL repair augmented with suture tape in a high-demand military population. We hypothesized that for proximal ACL avulsions, ACL repair with suture tape augmentation would lead to acceptable failure rates, satisfactory knee stability, excellent functional outcomes, and high rates of return to preinjury activity levels. Study Design: Case series; Level of evidence, 2. Methods: Patients who were treated with ACL repair by a single surgeon between March 2017 and June 2019 and who had a minimum of 2 years of follow-up were included. Intraoperatively, all patients first underwent an arthroscopic examination. If an ACL avulsion of the proximal insertion with adequate remaining tissue was visualized, then ACL repair was performed. The primary outcome assessed was ACL repair failure, defined as reruptures or clinical instability requiring revision to ACL reconstruction. Analysis of the risk factors for ACL repair failure was conducted, with age at surgery, sex, body mass index, level of competition, and tobacco use evaluated. Results: Included were 46 patients (32 male and 14 female; mean age, 28.3 ± 8.4 years) who underwent ACL repair with suture tape augmentation. There were 12 cases of failure (26.1%; 8 male and 4 female). The mean time from injury to surgery in the failure group was 164.1 ± 59.4 days compared to 107.3 ± 98.0 days in the nonfailure group ( P = .02). According to multivariate regression analysis, patients aged ≤17 and ≥35 years, elite/competitive/operational patients, and current smokers had a higher chance of ACL repair failure. The mean time to pass a military physical fitness test was 5.0 months. There were no complications other than ACL repair failure. Conclusion: Primary arthroscopic ACL repair with suture tape augmentation resulted in unacceptably high failure rates at a minimum of 2 years of follow-up in a highly active military population. Age ≤17 and ≥35 years, elite level of competition, time from injury to surgery, and active tobacco use were independent risk factors for ACL repair failure.

Rate of Revision Surgery and Associated Risk Factors After Primary Arthroscopic ACL Repair With Additional Suture Augmentation

“…Cruz et al 4 reported the highest revision rate after ACL repair with SA in a high-demand military cohort of 46 patients. At the 2-year follow-up, they found a revision rate of 26.1%.…”

“…Concomitant injuries were initially seen as a contraindication to performing an ACL repair with SA 6 ; however, studies have included patients with concomitant ligamentous, meniscal, and chondral lesions with an ACL injury but have not assessed them as potential risk factors for revision surgery. 7,12 In their analysis, Cruz et al 4 were not able to identify meniscal or The Orthopaedic Journal of Sports Medicine Revision Surgery ACL Repair 5 chondral concomitant injuries as a risk for revision surgery after ACL repair with SA. Cruz et al 4 reported a significantly higher mean interval between injury and surgery in the failure group (164 6 59 days compared with 107 6 98 days in the nonfailure group).…”

“…Nonetheless, with a mean time from injury to surgery of 96.8 677.4 days, the degree of strictness with which this cohort's patients were selected remains to be questioned, as the shortest injury-to-surgery interval was still longer than the longest interval within the presented cohort. 4 In a prospective cohort study, Douoguih et al 7 reported a revision rate of 10% in 30 patients undergoing ACL repair with SA. All 3 patients undergoing revision surgery sustained a traumatic retear: playing volleyball (17 months postoperatively), playing soccer in an Olympic development team (11 months after surgery), and playing competitive recreational soccer (12 months after surgery), respectively.…”

“…However, previous studies have described a younger patient age and a higher level of performed sports before injury as risk factors for a retear. Cruz et al 4 found that ages 17 and 35 years and performing sports at an elite level are independent patient-related risk factors for failure of the ACL repair with SA. However, in their systematic review, van Eck et al 8 reported contrary findings regarding patient age and concluded that ACL repair has ''a better outcome in younger patients, specifically in the skeletally immature.''…”

Defining Failure

“…A sampling of other recent studies of ACL repair, reconstruction, or revision reconstruction in AJSM and OJSM reveals a variety of definitions of failure, including history of giving way, 16,19,21,22 laxity on instrumented physical examination, 2,6,15,16,19,22 MRI evidence of disruption, 2,3,6,10,15,21,22 graft rupture by history, 11 symptomatic instability, 10 and rerupture or symptomatic instability requiring revision surgery. 3,6,10,11,16,21 Studies often used multiple criteria, and symptoms suggestive of possible failure frequently led to further documentation by instrumented examination and MRI. A letter to the editor by DiFelice and colleagues 5 suggested another nuance in the definition of failure in the case of ACL repair.…”