THEKNE-01827; No of Pages 4

The Knee xxx (2013) xxx–xxx

Contents lists available at ScienceDirect

The Knee

A novel technique, dynamic intraligamentary stabilization creates

optimal conditions for primary ACL healing:
A preliminary biomechanical study
Sandro Kohl a,b, Dimitrios S. Evangelopoulos a,c,⁎, Sufian S. Ahmad a, Heindrik Kohlhof a, Gudrun Herrmann d,
Harald Bonel e, Stefan Eggli a
a
Department of Orthopaedic Surgery, Inselspital, University of Bern, Switzerland
b
Robert Mathys Foundation, Bettlach, Switzerland
c
3rd Department of Orthopaedic Surgery, K.A.T. Hospital, University of Athens, Greece
d
Institute of Anatomy, University of Bern, Switzerland
e
Department of Radiology, Inselspital, University of Bern, Switzerland

a r t i c l e i n f o a b s t r a c t

Article history: Background: Anterior cruciate ligament (ACL) rupture is a common lesion. Current treatment emphasizes arthro-
Received 3 February 2013 scopic ACL reconstruction via a graft, although this approach is associated with potential drawbacks. A new meth-
Received in revised form 30 October 2013 od of dynamic intraligamentary stabilization (DIS) was subjected to biomechanical analysis to determine
Accepted 3 November 2013 whether it provides the necessary knee stability for optimal ACL healing.
Available online xxxx
Methods: Six human knees from cadavers were harvested. The patellar tendon, joint capsule and all muscular
attachments to the tibia and femur were removed, leaving the collateral and the cruciate ligaments intact. The
Keywords:
ACL
knees were stabilized and the ACL kinematics analyzed. Anterior–posterior (AP) stability measurements evaluat-
Dynamic intraligamentary stabilization ed the knees in the following conditions: (i) intact ACL, (ii) ACL rupture, (iii) ACL rupture with primary stabiliza-
AP stability tion, (iv) primary stabilization after 50 motion cycles, (v) ACL rupture with DIS, and (vi) DIS after 50 motion
cycles.
Results: After primary suture stabilization, average AP laxity was 3.2 mm, which increased to an average of
11.26 mm after 50 movement cycles. With primary ACL stabilization using DIS, however, average laxity values
were consistently lower than those of the intact ligament, increasing from an initial AP laxity of 3.00 mm to
just 3.2 mm after 50 movement cycles.
Conclusions: Dynamic intraligamentary stabilization established and maintained close contact between the two
ends of the ruptured ACL, thus ensuring optimal conditions for potential healing after primary reconstruction.
The present ex vivo findings show that the DIS technique is able to restore AP stability of the knee.
© 2013 Elsevier B.V. All rights reserved.

1. Introduction however, are often associated with pain, loss of proprioception,

Anterior cruciate ligament (ACL) rupture is a common lesion in ac-
tive adolescents and young adults. In an epidemiological study, Gianotti
et al. reported an incidence of 36.9 ACL surgeries per 100,000 person-
years [1]. Several predisposing factors, such as gender and type of
sport, are reported in the literature [2,3].
Current practice for the management of ACL rupture emphasizes the
arthroscopic reconstruction via a graft [4]. A number of alternative
methods for ACL reconstruction have been introduced since 1980,
each focusing on either the technique or the graft selection [5–12]. Al-
though recent techniques provide satisfactory scores and stability with
high levels of patient satisfaction, the midterm and long-term results
⁎ Corresponding author at: Department of Orthopaedic Surgery, University of Bern,
Freiburgstrasse, 3010 Bern, Switzerland. Tel.: +41 316323701; fax: +41 316323702.
E-mail address: ds.evangelopoulos@gmail.com (D.S. Evangelopoulos).
increased instability and risk of osteoarthritis [13–18].
Anatomically, the ACL is composed of closely packed collagen fiber
bundles arranged so as to resist tensile loads [19,20]. The healing
response of ligamentous tissue after injury is well documented in
other human ligaments, such as the medial collateral and fibulotalar
ligaments [21,22]. Primary suturing of the ACL was introduced as a
promising technique in the early 1980s and several surgical techniques
and materials have been developed for primary ACL reconstruction
(Dacron, Goretex, Marshall suturing) [23–26]. Their postoperative
results, however, have been disappointing, with limited regeneration
and numerous technical complications (broken braids, loosening, sig-
nificant anteroposterior laxity) indicating that the ligament has not
healed [27,28].
Recently Steadman et al. demonstrated histologically the healing
process of the ruptured PCL in experiments on animal models [29]. In
a clinical study using the same technique on skeletally immature

0968-0160/$ – see front matter © 2013 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.knee.2013.11.003

Please cite this article as: Kohl S, et al, A novel technique, dynamic intraligamentary stabilization creates optimal conditions for primary ACL
healing: A preliminary biomechanical study, Knee (2013), http://dx.doi.org/10.1016/j.knee.2013.11.003
2 S. Kohl et al. / The Knee xxx (2013) xxx–xxx
athletes with ACL rupture, the same authors reported survival analysis
results of 92% at N2 years and 70% at N 5 years [30]. In a biomechanical
study, Murray et al. found that suture repair of the ruptured ACL using
a bone tunnel in the central region of the ACL tibial insertion restored
AP stability to that of the intact knee, whereas other suturing techniques
failed to provide AP stability sufficient for the healing process [31].
A new technique for primary ACL stabilization, dynamic
intraligamentary stabilization (DIS) was developed at the authors' insti-
tution. It consists of a threaded sleeve housing a preloaded spring and a
mechanism for securing the spring in the tibia. A braided wire traverses
the knee joint through the middle of the torn ACL, exiting through the
lateral aspect of the femur where it is anchored with a button to the
bone (Fig. 1). The aim of the present study is to determine whether
the new stabilization system (DIS) provides adequate AP knee stability
for potential ACL healing.
2. Methods
2.1. Specimen preparation
The study was performed according to the ethical guidelines of the
Swiss Academy of Medical Sciences. Six human knees from four male
(two right and two left) and two female (one right and one left) Thiel
cadavers [32] were harvested for this study. The kinematics of Thiel
knees is similar to those of the normal living knee during biomechanical
testing. MRI was performed on all cadaver knees prior to selection to
exclude possible pathologies that could interfere with the tests. Inclu-
sion criteria were ligamentous integrity of the knee, the absence of oste-
oarthritis and a normal limb axis. Knees with ligamentous instability or
with degenerative lesions ≥ grade II according to the modified MRI
Outerbridge classification [33–35] were excluded from the study.
Cadaver femurs and tibias meeting these criteria were transected
approximately 20 cm from the joint space. The muscular attachments,
the patellar tendon, and the joint capsule were removed, leaving the
collateral and cruciate ligaments intact.
Fig. 1. ACL repair with the dynamic intraligamentary stabilization (DIS). The braid is fixed
on the femoral side with a button and on the tibial side at the intraosseus spring-loaded
screw.
Please cite this article as: Kohl S, et al, A novel technique, dynamic intraligamentary stabilization creates optimal conditions for primary ACL
healing: A preliminary biomechanical study, Knee (2013), http://dx.doi.org/10.1016/j.knee.2013.11.003
2.2. Biomechanical testing loading apparatus
AP laxity tests were performed using a universal tensile testing
machine (Zwick 1475, Ulm, Germany, resolution: 0.5 N/0.001 mm).
The tibial support was connected directly to the test system actuator
to perform the anterior drawer test. The knee was positioned at 60° in
order to simulate the anterior drawer test. The tibia was supported on
a 3D platform that allowed unconstrained axial rotation and translation
in the coronal and sagittal planes. The femur was supported on a fixed
platform, enabling the knee joint to maintain a constant proper neutral
position throughout the biomechanical testing. AP laxity was defined as
the total AP displacement between the AP shear load limits of − 5 to
+100 N.
The shear loads were applied directly to the tibia via the materials
testing system. To be consistent with clinical standards, laxity values
were reported as the displacement of the tibia relative to the fixed
femur.
2.3. Biomechanical testing protocol
The AP laxity of each of the 6 knees was measured. To ensure that
soft tissue incisions had no effect on AP laxity measurements, three
cycles were measured for every test and the average displacement
was recorded as the AP laxity value. The ACL was then transected with
a scalpel at the femoral footprint of insertion, and AP laxity tests were
repeated. The knees were then prepared for the primary repair proce-
dure: a bone tunnel was drilled with a K-wire using a commercial drill
guide system (Power Drive, Synthes, Inc.) to simulate the anatomical
course of the transected ACL. The entry point of the K-wire was on the
anteromedial aspect of the tibia progressing to the center of the tibial
footprint. A second K-wire was inserted from the medial compartment
of the knee, simulating the anteromedial portal, aiming at the center
of the femoral footprint and exiting the lateral femoral cortex. The
10:00 o'clock position was considered optimal for the right knees, the
2:00 o'clock position for the left knees. Through the K-wire a thermally
and mechanically prestressed polyethylene braid (diameter: 1.8 mm,
Young's modulus: 90 GPa) was placed through the ACL from the tibial
to the femoral side keeping the edges of the torn ligament in close con-
tact [36]. The suture was then tightened and fixed at the cortex of both
bones by means of a button with a preload of 85 N, with the knee at 30°
of flexion. AP laxity was calculated initially and after 50 cycles of full
flexion and full extension.
The braid was then removed and the DIS procedure performed. A K-
wire was drilled simulating the physiological course of the ACL from the
anteromedial aspect of the tibia through the ACL to the center of the
tibial footprint. A 10 mm spring-loaded screw was implanted in the
tibial side. The femoral K-wire was inserted as previously described
and a 1.8 mm suture was passed initially through the femur and then
through the spring-loaded screw. The braid was fixed on the femoral
side with a button and on the tibial side at the intraosseus spring-
loaded screw with a preload of 85 N (Figs. 2 and 3). Again, the AP laxity
was calculated initially and after 50 cycles of full flexion and full
extension.
3. Results
The DIS technique significantly improved AP laxity in all knees. Intact knees had an
average AP laxity of 7.8 mm (range 4.4–10.6 mm). When the ACL was sectioned, the
average knee laxity increased significantly to 18.75 mm (range 13.9–25.0 mm). After
primary suture stabilization, average AP laxity was 3.2 mm (range 1.7–3.9 mm). After
50 movement cycles, average laxity had significantly increased to 11.26 mm (range
7.3–14.5 mm) (p value b 0.05). DIS-stabilized knees initially exhibited an average AP
laxity of 3.00 mm (range 1.6–3.6 mm), which rose after 50 motion cycles to 3.2 mm
(1.9–3.9 mm), a non-significant increase (p value = 0.43) (Table 1) (Fig. 4).
For all measurements average laxity values for DIS at initial stabilization and after 50
motion cycles were always lower than those for the intact ligament, establishing and
maintaining close contact between the two ends of the ruptured ACL.
 S. Kohl et al. / The Knee xxx (2013) xxx–xxx 3

Table 1
Mean and SD laxity values (mm) of the six Thiel cadavers at six different tests.

Cadaver 1 2 3 4 5 6

Intact ACL Mean 9.5 8.5 7.3 10.6 6.3 4.4

SD 0.06 0.18 0.06 0.23 0.23 0.20
ACL rupture Mean 13.9 16.7 21.2 20.2 25.0 15.4
SD 0.23 0.05 0.14 0.16 0.42 0.11
Primary stabilization Mean 2.7 2.9 3.3 2.6 2.7 3.4
SD 0.06 0.06 0.15 0.15 0.21 0.06
Primary stabilization after Mean 7.3 10.5 14.6 9.8 12.8 8.6
50 motion cycles
SD 0.15 0.10 0.42 0.12 0.06 0.12
DIS Mean 1.6 2.1 3.0 2.9 3.4 3.6
SD 0.06 0.06 0.06 0.06 0.15 0.06
DIS after 50 motion cycles Mean 1.7 2.3 3.3 3.1 3.5 3.9
SD 0.06 0.10 0.06 0.10 0.10 0

problems at the harvest site, maintenance of proprioception, and dura-

Fig. 2. The course of the 1.8 mm diameter polyethylene braid and a cross section of the
intraosseus spring-loaded screw on the tibial side with a preload of 85 N.
4. Discussion
ACL rupture occurs in hundreds of thousands of active adolescents
and young adults each year [4]. The current standard treatment for
ACL rupture is minimally invasive arthroscopic ACL reconstruction
requiring graft harvest and a prolonged period of rehabilitation and
training. Another treatment, the recently developed double-bundle
technique, has produced encouraging immediate postoperative and
short term results for ACL reconstruction [37,38].
The notion of a surgical technique that would exploit the ACL's latent
capacity for self-healing is not new. Such a technique would possess
potential advantages over the classic arthroscopic technique with
regard to operation time, postoperative swelling and pain, functional
tion of the rehabilitation period.
Marshall et al. were the first to describe primary suture repair of the
ruptured ACL [23,24]. Their series however had a high re-rupture rate
and inconsistent improvement in AP laxity. The low success rate of the
primary suturing technique can be attributed to two main factors, one
biological and the other mechanical. Biologically, the physiological
peculiarities of the intraarticular space require a means to locally
increase chemotaxis and mitogenesis (bio-absorbable scaffolds for
growth factors application, microfracturing technique) [29,39,40]. Me-
chanically, the knee is not a ball-and-socket joint and has an additional
gliding component during flexion which increases the distance between
the two ends of the ruptured ACL and impairs the physiological healing
process, resulting in suture rupture [41,42]. Restoration of AP stability
after ACL repair is of major importance for maintenance of joint function
and prevention of early osteoarthritis [43,44]. But since absolute iso-
metric positioning of the braid is not always feasible, consequent loos-
ening is to be expected. The results of the present study demonstrate
that primary stabilization with a strong braid and a preload of 85 N
resulted in an AP drawer of 3.2 mm (range 1.7–3.9 mm). The AP laxity
increased to 11.26 mm (range 7.3–14.5 mm) after 50 cycles of full flex-
ion and full extension.
Fleming et al. performed an ex vivo study evaluating the ability of
five different suture repair constructs performed at two different joint
positions to restore normal AP stability. They found that suture repair
to bony fixation points within the anterior half of the normal ACL foot-
print resulted in knee stability values within 0.5 mm of those for the
intact ACL joint when the sutures were tied with the knee at 60° flexion,
whereas suture repair to the tibial stump or with the knee at 30° of

Fig. 4. AP laxity measurements (from left to right): (i) dynamic intraligamentary stabiliza-
tion, (ii) dynamic intraligamentary stabilization after 50 motion cycles, (iii) primary stabi-
Fig. 3. Anteroposterior and lateral x-rays demonstrating DIS stabilization on cadaveric lization, (iv) intact ACL, (v) primary stabilization after 50 motion cycles, and (vi) ACL
models. rupture.

Please cite this article as: Kohl S, et al, A novel technique, dynamic intraligamentary stabilization creates optimal conditions for primary ACL
healing: A preliminary biomechanical study, Knee (2013), http://dx.doi.org/10.1016/j.knee.2013.11.003
4 S. Kohl et al. / The Knee xxx (2013) xxx–xxx
flexion did not restore normal AP stability [31]. In contrast, the present
ex vivo biomechanical study using DIS achieved AP stability similar to
that of a normal knee at various degrees of flexion. An average anterior
drawer of 3.00 mm (range 1.6–3.6 mm) was recorded, which only mar-
ginally increased after 50 motion cycles of AP translation, to 3.2 mm
(1.9–3.9 mm). Intact knees had an average AP laxity of 7.8 mm (range
4.4–10.6 mm).
The DIS technique succeeded in providing continuous AP stability at
all degrees of flexion without loosening (polyethylene braid 3500 N,
elongation only 0.1%).
Deviation from the centers of tibial and femoral footprints during
ACL reconstruction may lead to graft elongation and potential loss of
AP stability. The DIS technique, however, can successfully restore AP
stability of the knee following ACL rupture. Further mechanical testing
and in vivo evaluation of this repair technique are warranted to deter-
mine whether it promotes ACL healing after primary repair.
5. Conflict of interest statement
The authors state that they have no conflicts of interest.
Acknowledgements
All authors state that no funds or any other commercial agreement
were received for the performance of this study.
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