Anterior cruciate ligament repair: The quest continues

Roy Antonius Gerhardus Hoogeslag

Research output: ThesisPhD Thesis - Research UT, graduation UT

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The purpose of this thesis was to investigate the role of modern anterior cruciate ligament (ACL) suture repair (ACLSR) in the treatment of ACL ruptures (ACL#).

We (1) performed a systematic review of the literature (SR) to critically appraise, summarize, and compare recent literature on outcomes of ACLSR; (2) in the human cadaveric knee, compared the biomechanical properties of two augmented and one historical non-augmented ACLSR techniques after cyclic loading, across the arc of knee flexion; (3) performed a randomized clinical trial (RCT) with two- and five-year follow-up on outcomes of DA ACLSR compared to ACLR; and (4) investigated whether the preoperative magnetic resonance imaging (MRI) scan could have predicted specific morphological ACL# characteristics in patients that underwent arthroscopic ACLSR in our RCT.

In the SR, we found that the amount of high-quality evidence for ACLSR is poor. This made it difficult to establish the role of ACLSR in the treatment of ACL#s. In the biomechanical study, we found that only DA resulted in restoration of anterior tibial translation values similar to those for the intact ACL, and lower than those for the ruptured ACL directly post-operation and after cyclic loading, across the arc of flexion of the knee. Furthermore, we found that the targeted isometric tunnel placement for the augmentation braid was not attained. This could lead to length-change in the tunnels’ distance across the arc of flexion of the knee, which can only be compensated by DA. In the RCT, we found that, in contrast to the result for non-inferiority of ACLSR compared to ACLR at two-year follow-up, the results at five-year follow-up were inconclusive. However, there were no statistically significant differences in any of the outcome measures between ACLSR compared to ACLR. Finally, we found that the assessment of specific ACL# characteristics of the preoperative MRI was not opportune, meaning that final assessment of a patient’s eligibility for ACLSR based on ACL# characteristics should be made at the time of (and not prior to) surgery.

This PhD shows that (1) there may be no difference in the outcome between modern ACLSR and ACLR; and (2) augmentation of the ACLSR with a strong, small- diameter braid positioned parallel to the ACL and shielding the ACL from (some) stress during healing may be one of the important pillars for the success of ACLSR.
Original languageEnglish
QualificationDoctor of Philosophy
Awarding Institution
  • University of Twente
  • Verdonschot, Nicolaas Jacobus Joseph, Supervisor
  • Brouwer, Reinoud W., Co-Supervisor, External person
  • Huis in 't Veld, Rianne , Co-Supervisor
Award date9 Nov 2022
Place of PublicationEnschede
Print ISBNs978-90-365-5457-2
Publication statusPublished - 9 Nov 2022


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