Knee Surg Sports Traumatol Arthrosc

DOI 10.1007/s00167-014-2949-x

KNEE

Dynamic intraligamentary stabilization: novel technique

for preserving the ruptured ACL
S. Eggli • H. Kohlhof • M. Zumstein •
P. Henle • M. Hartel • D. S. Evangelopoulos •

H. Bonel • S. Kohl

Received: 15 April 2012 / Accepted: 11 March 2014

Ó The Author(s) 2014. This article is published with open access at Springerlink.com

Abstract (IKDC), visual analogue scale patient satisfaction score]

Purpose Replacement of the torn anterior cruciate liga- and radiological evaluation, as well as assessment of knee
ment (ACL) with a transplant is today‘s gold standard. A laxity was performed at 6 weeks, 3, 6, 12, and 24 months.
new technique for preserving and healing the torn ACL is Results One patient had a re-rupture 5 months postoper-
presented. Hypothesis: a dynamic intraligamentary stabil- ative and was hence excluded from further follow-ups. The
ization (DIS) that provides continuous postinjury stability other nine patients presented the following outcomes at
of the knee and ACL in combination with biological 24 months: median Lysholm score of 100; IKDC score of
improvement of the healing environment [leucocyte- and 98 (97–100); median Tegner score of 6 (range 9–5);
platelet-rich fibrin (L-PRF) and microfracturing] should anterior translation difference of 1.4 mm (-1 to 3 mm);
enable biomechanically stable ACL self-healing. median satisfaction score of 9.8 (9–10). MRI showed
Methods Ten sportive patients were treated by DIS scarring and continuity of the ligament in all patients.
employing an internal stabilizer to keep the unstable knee Conclusions DIS combined with microfracturing and
in a posterior translation, combined with microfracturing L-PRF resulted in stable clinical and radiological healing
and platelet-rich fibrin induction at the rupture site to of the torn ACL in all but one patient of this first series.
promote self-healing. Postoperative clinical [Tegner, Lys- They attained normal knee scores, reported excellent sat-
holm, International Knee Documentation Committee isfaction and could return to their previous levels of
sporting activity.
Level of evidence Case series with no comparison group,
S. Eggli (&)
P. Henle Level IV.
Sonnenhof Orthopaedic Clinic, Swiss Leading Hospitals,
Buchserstrasse 30, 3006 Bern, Switzerland
Keywords Anterior cruciate ligament
Dynamic
e-mail: [email protected]
intraligamentary stabilization
Arthroscopic surgery

S. Eggli
H. Kohlhof
M. Zumstein
S. Kohl Sports injury
Knee injury
Department of Orthopaedic Surgery, Inselspital, University of
Bern, Freiburgstrasse, 3010 Bern, Switzerland

M. Hartel Introduction
Department of Trauma Surgery, University Medical Center
Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Rupture of the anterior cruciate ligament (ACL) is the
Germany
most common injury of the knee requiring surgical
D. S. Evangelopoulos treatment [18]. While a conservative treatment approach
3rd Department of Orthopaedic Surgery, University of Athens, leads to satisfactory results in a population that places low
Christovassili Street, Neo Psychikon, 15451 Athens, Greece demand on the knee joint [31, 41], persisting instability
prevents patients from participating in activities that
H. Bonel
Department of Radiology, Inselspital, University of Bern, require high levels of joint pivoting, such as soccer and
Freiburgstrasse, 3010 Bern, Switzerland skiing.

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Today’s gold standard in ACL repair was developed by Surgical technique

Brückner in 1966 and uses the middle third of the patellar
ligament as transplant to restore knee joint stability [10]. Each patient was placed in a supine position with the knee
Although arthroscopic techniques have improved tremen- positioned in a static knee holder with a tourniquet inflated
dously since then, and current ACL reconstruction tech- to 350 mm Hg. An antero-lateral portal was used for the
niques are an excellent option for restoring sagittal plane camera and an antero-medial portal for the instruments.
stability of the knee, the clinical results with tendon grafts The infrapatellar area was freed from the hypertrophic
are still under discussion. Despite numerous publications portions of Hoffa’s fat pad. Removal of too much tissue,
reporting good-to-excellent results, the meta-analysis of especially from the inferior part of the fat pad, was avoided
Biau et al. [8] revealed that only 40 % of patients achieve to preserve nutritional arteries to the ACL passing through
full recovery independent of surgical technique. One this area [2]. The tibial footprint of the ACL was marked
explanation could be that removal of the native ACL tissue using an intra-articular guide, and a wire was passed
containing sensory nerve fibres causes the ligament to lose through the tibia to this point. A 10.5-mm threaded sleeve
its function within the joint’s ‘proprioceptive envelope’ [3, (Mathys Ltd, Bettlach, Switzerland) was then inserted into
23], thus impairing muscular stabilization of the knee. the tibia. A suture passer was inserted through the screw
Based on this theory, the authors started to investigate a into the distal ACL stump, and a preliminary thread was
strategy for preserving the torn ACL in 2007. passed through the ligament. The femoral footprint was
The main challenge is posed by the torn ligament’s poor identified using a guide from the antero-medial portal, and
healing capacity. This can be partly explained by biological a wire was passed at 120 degrees of flexion to the lateral
factors such as cell deficiencies, alterations in cellular aspect of the femur. The wire was passed through the skin,
metabolism, the hostile environment of the synovial fluid and the definitive polyethylene wire was inserted from the
[12, 42], and the lack of blood supply [2, 26]. Moreover, antero-lateral femoral position to the antero-medial aspect
the postinjury instability does not allow the torn ligament
to heal.
While recent studies support the potential of biological
self-healing for the ruptured ACL [34, 35, 38], the per-
sisting postinjury translation in the antero-posterior plane
separates the ligament stumps by 5–10 mm and prevents
possible self-healing and formation of stable scar tissue [1,
16, 43]. To address this problem, a new technique was
developed, dynamic intraligamentary stabilization (DIS),
hypothesizing that continuous posttraumatic stabilization
of the knee can enable mechanically stable ACL healing.
Encouraged by the success of DIS in a sheep model [27],
the technique was applied in a series of 10 physically active
individuals with a torn ACL.

Materials and methods

Inclusion criteria were an ACL rupture not older than

14 days, patient age \45 years, no previous surgery on the
injured knee, and regular participation in sports requiring
pivoting of the knee joint. Ten consecutive patients (eight
males, two females) met the inclusion criteria and under-
went surgery between August 2009 and February 2010.
Median age was 25.4 years (range 19–41 years); the right/
left knee ratio was 7/3. The median accident-surgery
interval was 9.9 days (range 2–13 days). The rupture was
located in the middle third of the ligament in seven patients
and in the proximal third in three patients. Eight patients
showed additional meniscal lesions, which were surgically Fig. 1 Dynamic screw-spring mechanism pushes the tibia into a
treated in six patients. posterior translation at every degree of flexion

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of the tibia. The wire was stabilized at the femoral position 3 Tesla Scanner (Magnetom Verio; Siemens, Erlangen,
with a flip anchor. A metallic spring was inserted in the Germany) with a dedicated 15-channel knee coil.
screw, and the polyethylene wire was fixed with a cover at All examinations were reported in random order by a
the end of the screw at a tension of 80 N. The DIS tech- specialized radiologist with a more than 15-years experi-
nique holds the knee in a fixed posterior translation at every ence in musculoskeletal radiology. The radiologist was
degree of flexion, ensuring that the two ligament stumps blinded to all clinical information except for the surgical
are kept as close to each other as possible at all times repair of the ACL. First, image quality was assessed using
(Fig. 1). The surgery was then completed by microfrac- a 5-point scale (5 = optimal image quality, 4 = very good
turing of the femoral footprint and induction of a leuco- image quality, 3 = diagnostic image quality, 2 = ana-
cyte- and platelet-rich fibrin (L-PRF) clot at the rupture tomic structures only identified, 1 = anatomic structures
site. not seen). Next, the MRIs were examined for intactness of
Postoperative treatment consisted of the patient spend- the ligament by an independent evaluator applying the
ing 3 days in a fixed position with the knee fully extended. following criteria:
The leg was then loaded with 15 kg of weight for 3 weeks
and mobilized without any flexion limitations. Beginning at Morphology and continuity
4 weeks postoperative, the leg was loaded with full body
weight and reinforcement training of the quadriceps and The ligament tear was rated in three grades similar to those
hamstrings was initiated using closed chain knee exercises. used by Kühne et al. [28] after ACL repair, grade 3 rep-
Intensive proprioceptive training was initiated with a resenting a non-delineated ligament, grade 2 a wavy but
trampoline and balancing exercises on an unstable board. continuous ligament contour, and grade 1 a continuous
Running was allowed after 6 weeks and pivoting sports ligament.
after 3 months. Competitive soccer and skiing were
allowed after 5 months. Signal intensity

The 4-level grading system for the PCL, as proposed by

Clinical evaluation Howell et al., was adapted to analyse variations in the
signal intensity parameters of the graft [21]. In grade I, a
All patients were evaluated according to a prospective homogeneous, low-intensity signal was observed within
protocol, 6 weeks, 3, 6, 12, and 24 months after surgery. the entire graft segment. In grade II, at least 50 % of the
The following instruments were used for outcomes ‘normal’ ligament signal was observed. In grade III, the
assessment at each follow-up: Tegner score, Lysholm graft segment depicted less than 50 % of the normal liga-
score, the International Knee Documentation Committee ment signal. In grade IV, there was a diffuse increase in
(IKDC) score, and visual analogue scale (VAS) for signal intensity with abnormal ligament strands.
assessment of patient satisfaction (0 = completely dissat-
isfied, 10 = completely satisfied). The preoperative scores Statistical analysis
were assessed retrospectively using the same question-
naires. Knee laxity was assessed by measuring anterior To express the variability and distribution of the underlying
translation at 30 degrees flexion using a RolimeterTM data, the median values of outcome scores and their range
(Aircast, Neubeuern, Germany) and comparing it with the were calculated and reported. No inferential statistics were
contralateral knee. All patients were informed that their used in this exploratory descriptive study (n = 10).
treatment would involve a completely new technique, to
which they gave voluntary written informed consent
(Cantonal Ethics Committee of Berne, Switzerland: Ref.- Results
Nr. KEK-BE: 048/09, ISRCTN 89368687).
At 5 months after surgery, patient number 6 (a 24-year-old
male sports student) suffered from a re-rupture after sus-
taining a direct rotation trauma playing soccer. Until then,
Radiological evaluation the patient had been pain-free with a Lysholm score of 97
and a Tegner score of 5 at the 3 month follow-up. 6 weeks
Conventional radiographic evaluation was performed after the second trauma his completely ruptured ACL was
immediately after surgery and at the 6-week and 12-month replaced by a bone-tendon-bone (BTB) graft.
follow-ups. MRI investigations were conducted 6 weeks, 3, The remaining nine patients were all monitored
6, and 12 months after the intervention using an advanced according to the clinical follow-up protocol and had a

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Table 1 Clinical scores at Scores/tests Before injury 3 Months 6 Months 12 Months 24 Months
follow-up examinations
(median values and range) Lysholm 100 99.1 (97–100) 99.8 (99–100) 99.8 (98–100) 100
IKDC 100 92.1 (87–96) 94 (90–98) 97.8 (97–100) 98 (97–100)
Tegner 6 (4–9) 5 (4–6) 5 (4–8) 6 (5–9) 6 (5–9)
D Lachmann (mm) 0.5 (-3–3) 1.0 (-3–3) 1.2 (-2–3) 1.4 (-1–3)
Pat. satisfaction VAS 9.5 (8–10) 9.6 (9–10) 9.8 (9–10) 9.8 (9–10)

Fig. 2 Lateral MRI showing the torn ACL immediately after injury and at 12 months follow-up (after removal of screw)

complete set of MRI investigations. The Lysholm score Applying the Howell grading system, MRI signals were
was 100 before injury, 99 (97–100) after 3 months, and 100 rated I in 2 of the 10 patients after 6 weeks and II in the
after 24 months. The IKDC score reached 98 (97–100) remaining 8 patients. After 3 months and for all later
after 24 months, and with six points the group‘s median assessments, the signals were rated I for all patients except
Tegner activity score remained the same as before the patient number 6 after the second rupture of his ligament
accident. After 3 months, the anterior translation difference (Fig. 2).
was 0.5 mm (-3 to 3) compared with the contralateral side
and 1.4 mm (-1 to 3) after 24 months. Before surgery, it
was 4.9 (range 3–7 mm, SD 1.2 mm). The anterior stop Discussion
was hard in three patients and semi-hard in six patients.
Median patient satisfaction was 9.5 (8–10) after 3 months The most important finding of the present study was that a
and 9.8 (9–10) after 24 months (Table 1). dynamic intraligamentary stabilization of the knee with a
freshly ruptured ACL in combination with biological
MRI improvement of the healing environment can lead to a
biomechanically stable ACL with good functional scores
Imaging quality was rated as optimal (score 5) in nine and high patient satisfaction.
patients and very good (score 4) in one patient at 6 weeks. ACL rupture is a devastating knee injury that is associ-
Metal artefacts were detected at the site of the implanted ated with a significant risk of developing osteoarthritis [15].
spring mechanism. Metal artefacts obscured 18 % of the Controversially, this risk is reported to be even higher in
distal ACL (range 12–23 %) but did not alter the mor- patients undergoing surgical stabilization of the ACL [11,
phology of the proximal and middle third of the ligament. 25, 29]. These problems may be attributable to loss of
Continuity was rated as grade A, or ‘well defined’, in all proprioception after complete removal of the ACL [5, 31,
nine patients at all times. Patient number 6 was also rated 37] as well as to insufficient restoration of the three-
grade A before his re-rupture. All repairs were well dimensional stability of the knee [6, 36, 39]. It was therefore
defined, and ligament continuity was fully restored. hypothesized that conservation of the native ACL tissue is

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necessary to preserve proprioception and restore the indi- delivery of growth factors; in particular, L-PRF can be used
vidual three-dimensional anatomy of the ligament. as a regenerative in situ tissue engineering method during
The paradigm that a torn ACL has insufficient healing treatment of ACL injuries. This technique was adapted in
capacity and must be replaced by a tendon graft remains combination with microfracturing according to Steadman
prevalent [14, 20]. Opposing this paradigm, a series of to optimize the biological healing capacity of the ACL.
publications have indicated that under certain circum- The MRI investigations at 3, 6, and 12 months showed a
stances the injured ACL can produce a stable scar. Träger continuous increase in scar tissue as represented by fibres
et al. [43] reported a better clinical outcome and improved of low signal intensity. In addition, clear remodelling of the
stability with suturing the ACL and augmenting the tissue ligament was detectable at 6 months, and the independent
with polydioxanone than with ACL replacement. Steadman evaluator judged the continuity of the ligaments as
et al. [40] described a method known as the ‘healing restored. Furthermore, the dynamic aspect of the repair
response’ wherein placement of undifferentiated stem cells resulted in a straight appearance of the fibre bundles
into the rupture zone induced stable healing of the torn without the wavelike morphology observed with other
ACL in an athletically active, skeletally immature patient. surgical techniques.
In 2002, Fujimoto et al. [17] published the results of 31 Clinically, all patients exhibited practically normal knee
ACL ruptures in patients with low athletic demands treated function after 1 year with a Lysholm score of almost 100
conservatively for 2–3 months with an extension block soft and an IKDC score of 98. These results are strikingly
brace without anterior stabilization: 23 knees (74 %) were improved in comparison with the outcome after conven-
stable with a continuous ACL on MRI at final follow-up. tional ACL repair with a tendon graft. However, the
Boldrini et al. [19] reported stable healing in 26 athletes reported ceiling effects of the Lysholm score need to be
with an incomplete ACL tear using primary sutures in considered in this series of highly motivated and active
combination with bone marrow stimulation. patients [9]. A better discriminating outcome instrument
The literature to date indicates that stability and biology may be needed for these types of patients in the future. In
are the two main determinants for ACL healing. Every their meta-analysis, Biau et al. [8] reported that only about
tissue demands a certain level of stability to heal [24], but 40 % of patients made a full recovery after ACL recon-
since a knee with an injured ACL shows a significant struction, with only 33 % having a normal IKDC score
increase in antero-posterior translation of the tibio-femoral after a semitendinosus transplant and 41 % having a nor-
joint [13], normal knee movements result in a constant mal IKDC after a BTB (ligamentum patellae) transplant.
disconnection of the two ACL stumps, creating an unstable Thus, more than 60 % of patients (708 of 1,125 for the two
healing environment. The published method of knee reconstruction groups) did not fully recover (final overall
bracing in a constant posterior translation for 3 months has IKDC score class A) after reconstruction.
already produced a remarkable number of healed liga- The present authors attribute the excellent clinical
ments, but it is not widely accepted because of the dis- results of their new technique to the restored stability of the
comfort it causes [17, 22]. The authors have developed a knee on one hand, but even more to the preservation of the
new technique called dynamic intraligamentary stabiliza- ACL tissue, which allows for the restoration of a physio-
tion (DIS) that restores the intrinsic stability of the knee logical proprioception. Barret points out that ligament tests
with minimal discomfort for the patient. The DIS device and knee scores correlate poorly with patient satisfaction
employs an internal screw-spring mechanism that acts as a scores, but proprioception is a major factor in measuring
dynamic internal fixator which pushes the knee into a the overall outcome of ACL reconstruction [4]. Patients in
maximum posterior translation in any degree of flexion. the present study reported a satisfaction of 9.8 on VAS
The spring is also functional when the intraligamentary after 1 year, indicating that healing of the ACL tissue may
thread is not placed in an isometric position. This technique restore not only the three-dimensional stability of the knee
has already been shown to provide sufficient mechanical but also the physiological proprioceptive envelope. Caste-
stability to enable biomechanically stable healing of the leyn states that the real benchmark of success in the
ACL in a sheep model [27]. treatment of ACL ruptures has to be the avoidance of
Recent studies have demonstrated that introduction of a treatment morbidity, secondary surgery, and osteoarthritis
collagen-platelet composite into a transected ACL can [11]. In the meta-analysis of Biau et al. [7], 13–22 % of the
significantly increase its healing capacity [30, 32, 33]. patients complained of persisting knee pain, mainly asso-
Murray et al. [32] used a collagen-platelet composite to ciated with donor-site morbidity. The DIS technique
bridge the wound site and reported healing with recovery requires no additional ligament extraction, thus minimizing
of over 50 % of the initial ligament strength after 4 weeks. the surgical trauma.
Zumstein et al. [44, 45] have demonstrated that solid There are limitations to this study. The sample size is
scaffolds can be used for long-term (up to 28 days) small, there is no control group, and the follow-up is not

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long enough to address posttraumatic arthritis, which 8. Biau DJ, Tournoux C, Katsahian S, Schranz P, Nizard R (2007)
results in an evidence level of only IV. ACL reconstruction: a meta-analysis of functional scores. Clin
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The authors conclude that this study could revitalize the 9. Briggs KK, Kocher MS, Rodkey WG, Steadman JR (2006)
discussion of preserving the torn ligament. It could be an Reliability, validity, and responsiveness of the Lysholm knee
additional option between the conservative treatment and score and Tegner activity scale for patients with meniscal injury
the replacement of the ACL. Further studies need to be of the knee. J Bone Jt Surg Am 88(4):698–705
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12. Darabos N, Hundric-Haspl Z, Haspl M, Markotic A, Darabos A,
Dynamic intraligamentary stabilization in combination with Moser C (2009) Correlation between synovial fluid and serum IL-
L-PRF and microfracturing of the notch can lead to stable 1beta levels after ACL surgery-preliminary report. Int Orthop
clinical and radiological healing of the torn ACL after 33(2):413–418
13. Dejour H, Bonnin M (1994) Tibial translation after anterior
1 year. Patients exhibited normal knee function reported cruciate ligament rupture. Two radiological tests compared.
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325:4–9
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Acknowledgments The authors thank D. Delfosse and A. De Orthop 15(4):367–371
Cesaris for their innovative engineering of the DIS prototypes and the 16. Fleming BC, Carey JL, Spindler KP, Murray MM (2008) Can
mechanical testing of the implants. This study was funded by the suture repair of ACL transection restore normal anteroposterior
Swiss National Accident Insurance Fund. laxity of the knee? An ex vivo study. J Orthop Res
26(11):1500–1505
Conflict of interest The authors declare that they have no conflict 17. Fujimoto E, Sumen Y, Ochi M, Ikuta Y (2002) Spontaneous
of interest. healing of acute anterior cruciate ligament (ACL) injuries—
conservative treatment using an extension block soft brace
Open Access This article is distributed under the terms of the without anterior stabilization. Arch Orthop Trauma Surg
Creative Commons Attribution License which permits any use, dis- 122(4):212–216
tribution, and reproduction in any medium, provided the original 18. Gianotti SM, Marshall SW, Hume PA, Bunt L (2009) Incidence
author(s) and the source are credited. of anterior cruciate ligament injury and other knee ligament
injuries: a national population-based study. J Sci Med Sport
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