Independent Suture Tape Reinforcement of Tripled Smaller-Diameter and Quadrupled Grafts for Anterior Cruciate Ligament Reconstruction With Tibial Screw Fixation: A Biomechanical Full Construct Model

Arthroscopy. 2020 Feb;36(2):481-489. doi: 10.1016/j.arthro.2019.06.036. Epub 2019 Dec 31.


Purpose: To compare the effect of independent suture tape reinforcement on the dynamic elongation and stiffness behavior as well as ultimate strength of tripled smaller-diameter and quadrupled soft-tissue grafts for anterior cruciate ligament reconstruction (ACLR) with tibial screw fixation in a biomechanical in vitro study.

Methods: Tripled smaller-diameter (8 mm) and quadrupled (9 mm) bovine tendon grafts with and without suture tape reinforcement (n = 8 in each group) were tested using femoral suspensory and tibial interference screw fixation. The suture tape was femoral sided and fixed independent from the graft by passing it through the suspensory button and securing the 2 open tibial strands with a secondary interference screw. Dynamic testing was performed in position and force control at 250 N and 400 N, followed by pull to failure with the mode of failure noted. Dynamic elongation, stiffness, and ultimate strength were analyzed.

Results: Tripled constructs showed a significantly worse structural performance than quadrupled constructs at higher loads. Reinforcement of tripled and quadrupled grafts substantially decreased total elongation by 56% (4.54 ± 0.75 mm vs 2.01 ± 0.50 mm, P < .001) and 39% (3.25 ± 0.49 mm vs 1.98 ± 0.51 mm, P < .001), respectively, by significantly increasing dynamic stiffness. No statistical significance was found between the reinforced groups. Failure loads of reinforced tripled (1,074 ± 148 N vs 829 ± 100 N, P = .003) and quadrupled (1,125 ± 157 N vs 939 ± 76 N, P = .023) grafts were also significantly improved.

Conclusions: Independent reinforcement of soft-tissue grafts with suture tape strengthened the performance especially of tripled smaller-diameter grafts for ACLR with tibial screw fixation by significantly improving dynamic elongation at increased stiffness and ultimate strength. Quadrupled reinforced grafts showed no over-constraining and structurally behaved similarly to tripled grafts with reinforcement.

Clinical relevance: Independent reinforcement for ACLR may provide an option for protecting autografts or allografts against irreversible lengthening during the maturation and remodeling phases of healing.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Animals
  • Anterior Cruciate Ligament / physiopathology
  • Anterior Cruciate Ligament / surgery*
  • Anterior Cruciate Ligament Injuries / physiopathology
  • Anterior Cruciate Ligament Injuries / surgery*
  • Anterior Cruciate Ligament Reconstruction / methods*
  • Biomechanical Phenomena
  • Bone Screws*
  • Disease Models, Animal
  • Humans
  • Suture Techniques / instrumentation*
  • Sutures*
  • Swine
  • Tendons / transplantation*