A clinical practice review: augmentation of meniscoligamentous structures for primary prevention of knee joint deterioration

Introduction

Meniscoligamentous injury of the knee is a significant risk factor for development of osteoarthritis (OA) and deterioration of the joint (1,2). Of these injuries, meniscal tears are one of the most common pathologies with an estimated incidence of up to 222 per 100,000 in those aged 18 to 55 years old (3,4). Historically, meniscectomy served as the primary surgical treatment for meniscal injuries with the functional goal of symptom relief (4). However, more recent biomechanical and clinical evidence has demonstrated disruption of normal knee kinematics and an increased incidence of OA in the meniscus-deficient knee (4-6). Recent literature highlights a growing trend away from meniscectomy and toward meniscal preservation, namely arthroscopic meniscus repair (7-9).

Optimization of meniscus repair remains an important clinical issue. Clinical failure rates for arthroscopic meniscus repair are reported to range from 19–25% and several risk factors for failure have been identified including medial meniscus injury, lack of a concomitant ACL reconstruction (ACLR), increased time to surgery, and repair in a poorly vascularized zone (10-15). Recent studies have proposed biologic augmentation at the time of surgical repair may decrease failure incidence, but strong clinical evidence remains limited (10,16).

Ligamentous injuries, especially anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) tears, are also associated with increased rates of OA and injury to other structures in the joint including meniscus and cartilage (17-20). Although ACLR improves joint mechanics and stability, incidence of OA remains high, with reported OA rates of 23% following anatomic reconstruction and 44% following non-anatomic reconstruction at a minimum of 10 years postoperatively (19,21,22). Furthermore, while ACL graft failures occur in around 5% of patients, clinical failures are reported to occur more frequently, up to 40% in young, active populations (23,24). Along with ACL tears, PCL injuries have been shown to alter patellofemoral and medial compartment kinematics and are also associated with joint deterioration in long-term follow up (25-28).

Recent technological advances have expanded augmentation techniques for meniscoligamentous injury with the potential to improve outcomes associated with initial treatment, which may ultimately improve long term joint preservation. Augmentation techniques broadly fall into 4 main categories: suture, scaffolds, allografts, and biologics. Suture augmentation techniques provide additional mechanical stability through repair and reconstruction reinforcement (29). Scaffolds, either synthetic or biologic, provide additional structure and ultimately supports natural tissue ingrowth and remodeling (30). Allografts provide mechanical strength and the ability to integrate into host tissue when autografts are undesirable, unnecessary, or inadequate. Finally, biologic innovations like platelet-rich plasma (PRP) and cell-based therapies may optimize a healing environment in meniscus and ligament surgery (31,32). As these techniques evolve, understanding the mechanisms, applications, and clinical outcomes associated with them will be essential for guiding their use in the field of sports medicine. This article aims to provide an up-to-date, overview of the current literature on strategies and technological advances in augmentation of meniscoligamentous structures.

Suture augmentation

Suture augmentation of the ligaments of the knee refers to a surgical technique in which high-strength suture material (often ultra-high-molecular-weight polyethylene suture) is used to reinforce a primary ligament repair or to augment a graft in ligament reconstruction. The primary function of the suture augmentation is to increase biomechanical graft properties and create a load-sharing effect or to protect the graft at early postoperative stages (33-37). The overall complication rate of suture augmentation techniques is low (29,34,38). Concerns on ligament stress shielding and a negative impact on graft healing may be the downside, but literature remains scarce on biological graft healing after suture augmentation (29,39).

ACLR

In active individuals and athletes, ACLR is the current gold standard (40,41). Despite advancements in individualized treatment, surgical techniques, and rehabilitation protocols, the re-injury rate of ACL grafts remains up to 11–19%, particularly among young patients, females, and athletes involved in pivoting sports (24,42). Graft failure after ACLR often occurs in the first years after ACLR (43,44). The concept of adding suture augmentation to the ACL graft was introduced to provide stability and protection (37,45,46). The structural support is intended to be most effective during the early postoperative period, facilitating immediate mobilization, while the biological graft undergoes the process of ligamentization (45). Biomechanical studies have shown that suture augmentation led to earlier ACL graft load sharing, reduced elongation, increased stiffness, and significantly improved failure load compared to non-augmented ACL graft constructs (37,46). Risk of stress shielding, where the graft is protected from physiologic loads and thus may not remodel optimally, is currently not supported by animal studies or clinical data but remains a concern (45,47,48). Furthermore, the impact of suture augmentation on ligament healing is still largely unknown (47,48). In ACL repair, suture augmentation may increase the load to failure at time zero when compared to ACL repair alone (49).

Posterior cruciate ligament reconstruction (PCLR)

Knee laxity after PCLR is common and is reported in up to 12% as a leading cause for patients to undergo revision PCL surgery (50,51). Suture augmentation of the PCL graft may be one option to reduce instability after primary PCLR. Biomechanical studies on PCLR with suture augmentation demonstrate improved initial graft stability, with significant reductions in posterior tibial translation and increased load to failure (50). Regarding clinical outcomes, data remains less definitive as some studies report improved or equivalent patient-reported outcomes (PROs) and return-to-sport rates with suture augmentation compared to standard PCLR (52-54). The differences in validated outcome scores do not consistently reach the minimal clinically important difference (MCID) (50,55). Long-term clinical data on suture augmentation in PCLR are scarce, but short-term outcomes show promising results in reducing PCL graft laxity with a low complication rate, potentially displaying favorable long-term outcomes in the future (50,52,56).

Medial collateral ligament (MCL) repair

Injuries of the MCL mostly occur concomitantly with ACL injuries (57,58). In high-grade valgus instability, MCL repair or MCL reconstruction techniques typically involve direct suture repair of the torn ligament to its anatomic origin or insertion. Augmented repair may incorporate high-strength suture anchored at the femoral and tibial footprints (36,59). Biomechanical data indicated that suture augmentation of MCL repair in an ACLR-MCL injury model significantly improved valgus instability compared to MCL repair alone (60). Furthermore, posteromedial suture augmentation reduces rotatory medial instability of the knee and reduces ACL strain (33). Clinical outcome studies report good outcomes on MCL repair with augmentation after high-grade MCL injury, but the necessity of suture augmentation remains debatable (61,62). The varied results may arise from a lack of consensus on the objective evaluation of MCL grading, which affects the indication for surgical treatment, as multiple factors contribute to different forms of medial knee instability (63,64).

Lateral collateral ligament (LCL) reconstruction

Suture augmentation in LCL repair and posterolateral corner (PLC) reconstruction is increasingly utilized to enhance the biomechanical stability of repairs, particularly in the treatment of multiligament knee injuries (29,34,65). Suture augmentation in LCL enhances early controlled weightbearing without compromising varus instability (38). In cases of posterolateral rotatory instability, chronic PCL instability, and multiligamentous injuries, reconstruction of the PLC may be indicated. In acute PLC injuries, reconstruction showed lower revision rates than repair of the PLC (35). Biomechanical data indicate an increased resistance to posterior tibial displacement and external rotation with suture augmentation compared to reconstruction alone, but neither technique fully restores posterior translation to intact levels (66).

Scaffolds

Meniscus scaffold augmentation

Scaffolds expand upon a simple structural augmentation of a repair or reconstruction as with suture augmentation. The goal of a scaffold is to provide a porous matrix which the body can fill with autologous cells and regenerative tissue, ultimately leading to a well-integrated biological structure. They are indicated for post-meniscectomy syndrome with meniscus deficiency >25%, at least 1–2 mm of intact rim, and intact roots (67,68). Ideally, a meniscus scaffold candidate will have neutral alignment and ligamentous stability or have these factors addressed before or at the time of surgery (69). Grade III or IV Outerbridge cartilage wear is a risk factor for failure and therefore scaffold use should be reconsidered in the setting of advanced degenerative changes (70). Once a meniscal scaffold is indicated, there are two primary implants: collagen-based and synthetic polymer based.

Collagen-based implants are made up primarily of type 1 collagen derived from bovine Achilles tendon (71). Currently, there is a collagen-based meniscus scaffold approved for use in the United States and this has been the subject of most current studies. In general, short-term outcomes are promising although long-term outcomes, up to 20 years in one study, are less consistent (72). Studies are heterogenous with variations in populations and indications, although use in both medial and lateral meniscal deficiencies are represented (72). One study reports almost 80% of patients describe “excellent” or “good” outcomes at 10 years, however this same study demonstrates Tegner scores never reach preinjury levels and one study demonstrates Tegner scores regress back to preoperative levels at 10 years (73,74). VAS scores drop by around 50% in short-term outcomes with some studies suggesting maintenance of this up to 20 years although others demonstrate increases in pain after 10 years (73-75). Survival rates around 85% at 10 years have been reported, with lateral meniscus augmentation a risk factor for failure (73). Long term magnetic resonance imaging (MRI) follow-up has demonstrated MRI appearance similar to native meniscus although more than half of patients will develop bone marrow edema, degenerative changes, and meniscus extrusion at long-term follow-up (70,73,74,76). A second look arthroscopy study has demonstrated meniscus-like tissue formation on the scaffolds at 1 year (77). An example of a collagen-based meniscus scaffold can be seen in Figure 1.

Figure 1 Photograph of a collagen meniscus implant. Wang D, Gonzalez-Leon E, Rodeo SA, et al. Clinical Replacement Strategies for Meniscus Tissue Deficiency. Cartilage 2021;13:262S-70S. Copyright © 2021, Sage Publications. Reprinted by Permission of Sage Publications.

The most commonly used synthetic polymer scaffold is polyurethane based and biodegradable in nature. PROs are quite variable across studies and, like with the collagen implant, Tegner scores often do not reach preinjury level and one study demonstrates they do not improve more than meniscectomy alone at 5 years (78-82). VAS pain scores improved by 2 to 4 points in midterm follow up, similar to results with the collagen-based implant (83,84). Although not directly compared, MRI studies demonstrate a lower percentage of the polyurethane scaffolds appear similar to native meniscus compared with the collagen scaffold (78,85,86). Failure rates at 5–10 year follow up range from 6% to 38% (72,78,87). Despite this variability, multiple studies directly comparing collagen and polyurethane scaffolds did not demonstrate any differences between the two with respect to PROs, return to activity, or failure (84,88,89). A summary of implant options is listed in Table 1.

Ligament scaffold augmentation

Scaffold techniques have also been employed in ligament surgery. As with meniscus augmentation, scaffolds in ligament augmentation can be divided into collagen-based and synthetic-based implants. These implants have a hybrid function in that they provide some initial stability while also providing a scaffold for biologic integration. A bioinductive collagen scaffold reinforced with poly-L-lactic acid (PLLA) has been described for use in ACLR augmentation as well as MCL repair/reconstruction augmentation (90-92). Currently, clinical outcome data is limited, although its use is the subject of multiple ongoing clinical trials in knee ligament surgery.

A non-absorbable polyethylene terephthalate-based scaffold has been shown to demonstrate similar patient reported outcomes and failure rates to autograft in ACLR and PCLR at short- to mid-term follow-up, although the augmentation of autograft with the scaffold did not improve upon autograft alone (93-96). Some studies have demonstrated favorable outcomes with this specific scaffold compared to autograft although longer-term follow up at 6 years demonstrates high failure rates of 33% (94,97,98). A newer, absorbable polyurethane urea scaffold has recently gained Food and Drug Administration (FDA) approval and has been used in MCL augmentation and revision ACL augmentation (99,100). These innovations offer promise for future use in ligament augmentation although significantly more clinical outcomes research is necessary to guide their use. Examples of collagen-based and synthetic-based scaffolds can be seen in Figure 2.

Figure 2 Examples of scaffold use in ligament reconstruction and repair. (A) Collagen-based scaffold used for ACL reconstruction augmentation. (B) Collagen-based scaffold used for MCL repair augmentation. (C) Synthetic based scaffold used for MCL repair augmentation. ACL, anterior cruciate ligament; MCL, medial collateral ligament.

A final application of scaffold use in ligament surgery is a specific implant used in ACL repair. The bridge-enhanced ACL repair (BEAR) procedure was developed to improve outcomes associated with ACL repair by providing a matrix of bovine-derived type 1 collagen soaked in autologous blood to maintain an environment conducive to healing at the repair site (101). The initial nonrandomized, prospective study comparing the BEAR procedure to autograft hamstring reconstruction demonstrates similar outcomes with improved hamstring strength in the BEAR group at 6 years (102). A randomized controlled trial replicated these results, demonstrating noninferiority to ACLR with autograft at 2 years (103). While these early outcomes are encouraging, more work is needed to better understand the indications for the procedure, especially in terms of injury and patient characteristics. A summary of ligament scaffold augmentation strategies is listed in Table 2.

Allograft augmentation

Meniscal allograft transplantation (MAT)

With advances in surgical technique, MAT is a viable surgical option for select patients with symptomatic meniscal deficiency in either compartment (104-108). Young, active patients who have undergone subtotal or total meniscectomy are especially well-suited candidates to undergo such a procedure. Studies in this population, particularly those younger than 30, have demonstrated significant improvements in PROs (106,109-112). Although outcomes remain most favorable in younger individuals, MAT has also been shown to provide symptomatic relief and functional improvement in patients over the age of 50 years (113). Traditionally, classic contraindications for MAT include advanced OA and other degenerative articular cartilage defects (104,114,115). However, with the development of cartilage restoration procedures such as osteochondral allograft (OCA) transplantation, patients with such cartilage damage may now still be considered for MAT (104,116-118). Interestingly, despite these advances, patients who underwent concomitant cartilage restoration procedures in addition to MAT exhibited no differences in PROs and failure/reoperation rates at 2 years post-operation, calling into question the reported clinical benefit of combining these procedures (119).

MAT is an established surgical procedure that has been shown to reduce compartmental pain (104,105,116) and improve function in the meniscus deficient knee (106,119,120). Multiple mid- to long-term studies have reported graft survival rates of 70–90% at 5 years and 50–70% at 10 years, with mean survival times ranging between 7.5 and 11.5 years (104,116,121-123). A major predictor of long-term MAT success was cartilage health at the time of surgery with poorer outcomes being correlated in patients with increased chondral damage (106,117). Importantly, compliance with post-operative rehabilitation protocol has also been found to be a significant predictor of successful outcomes. Patients who were compliant with their rehabilitation protocol were 6 times less likely to require revision or total knee arthroplasty (124).

However, despite favorable mid- to long-term outcomes, MAT is not without risks and complications. Associated complications include graft failure, chondral damage, shrinkage, extrusion, infection, arthrofibrosis, aseptic synovitis, and bone plug loosening (104,125,126). Reported failure rates following MAT ranged from 12–23% (116,122,123). Reoperation rates were also not uncommon, with reported rates ranging from 22% in adolescent patients to as high as 54.2% for patients who underwent MAT and OCA (123,127,128). Notably, proper graft size is an important predictor for success. Grafts that were 5 mm undersized in width were found to significantly increase failure rates (129).

Currently, there are two main types of MAT fixation techniques: all-soft-tissue fixation and bone block fixation. With soft tissue fixation, meniscus roots are fixated directly to the tibia typically through transosseous tunnels while bone-block fixation takes advantage of bony plugs at the roots for bone-to-bone healing (130,131). While some studies suggest lower rates of extrusion and improve tibiofemoral contact pressures with the bone block technique, a majority of studies have found no significant differences between the two fixation techniques in terms of function and clinical outcome (132-138). An example of an all-soft tissue preparation of MAT can be seen in Figure 3.

Figure 3 Meniscus allograft for meniscus transplant procedure. (A) Right knee medial meniscus allograft, with junctions of the MB with the AH and PH marked. (B) The roots are removed off their insertions for all-soft-tissue technique and planned suture fixation points are marked with dotted lines. AH, anterior horn; MB, meniscus body; PH, posterior horn.

Allograft use in ligament reconstruction

Beyond meniscal preservation, allograft tissue has also become an important option in ligament reconstruction. In ACLR, allografts are particularly attractive due to the absence of donor-site morbidity and the predictability of graft size (139-141). The use of allografts may be especially useful in patients who lack adequate autograft tissue, have multi-ligament knee injuries, or require revision surgery (142). However, it is well described that allografts confer a higher risk for ACL graft failure than autografts, especially in young, active individuals under the age of 25 years (140,143-145). In patients over the age of 34–40 years, clinical outcomes have been found to be similar between patients who received autografts and allografts (145,146). In PCL and other collateral ligament (MCL and LCL) reconstruction procedures, allografts have also been shown to be suitable alternatives to autografts (147-149).

In addition to serving as a primary graft source, allografts may also be used to augment insufficient autografts. Hybrid grafts, created by combining autograft and allograft tissue, have demonstrated comparable outcomes to primary ACLRs performed using solely autograft tissue (150-152). Looking specifically at graft size, no differences were found in outcomes with graft diameters greater than 8 mm between autograft only and hybrid grafts (152). However, it has been shown that the rate of graft failure in patients with large-diameter hybrid grafts was lower than those with smaller-diameter autografts (153). Compared to ACLR procedures performed with soft tissue allograft, hybrid grafts have been found to be 2 times less likely to require aseptic revision surgery (154). Taken as a whole, allograft augmentation for undersized autografts may represent a potential strategy to improve graft survival and reduce revision rates, particularly in young, highly active patients.

Biologic augmentation

Commonly used biologics in meniscus and ligament injuries

Various biologic therapies have been explored to improve the healing of meniscal and ligamentous injuries, which otherwise may be predisposed to poor or delayed healing due to limited vascularity (12,155). The most commonly studied biologics include PRP, cell-based therapies using mesenchymal stem/stromal cells (MSCs), and fibrin clots (16,155). Each of these interventions aims to enhance the intrinsic repair environment of the tissue (12,16,155). PRP is an autologous concentrate of platelets and growth factors obtained via blood centrifugation (16,156). It delivers high concentrations of cytokines and growth factors, such as platelet-derived growth factor (PDGF), human transforming growth factor-beta 1 (TGF-β1), vascular endothelial growth factor (VEGF), and insulin-like growth factor-1 (IGF-1), directly to injury sites, which may stimulate cell proliferation, angiogenesis, and matrix synthesis (10,157). Cell-based therapies typically involve MSCs harvested from bone marrow or adipose tissue (16,158,159). These cell-based therapies may contribute to repair by secreting growth factors and modulating inflammation via paracrine signaling (158,160). Lastly, a fibrin clot is an autologous blood-derived scaffold rich in fibrin and platelets, placed at the site of a tear as a provisional matrix (10,16). Fibrin clots contain chemotactic factors, including PDGF and fibronectin, that can attract reparative cells and bridge avascular meniscal zones (10,16). Early animal and clinical studies support the idea that placement of a fibrin clot can stimulate healing (161,162).

Biologics in meniscus augmentation

Meniscus biologic augmentation is a strategy to overcome the limited healing capacity of the meniscus, which is largely avascular and can be prone to up to a 25% failure rate after repair (10,163). The concept emerged in part from the observation that meniscal repairs heal better when performed alongside ACLR, presumably because the ACL tunnel bleeding and marrow elements create a more favorable healing environment (164,165). This prompted interest in mimicking these effects with targeted biologic agents in isolated meniscus repairs (10). The main agents studied include PRP, fibrin clots and MSCs, each aiming to enrich the repair site with growth factors, chemotactic signals or regenerative cells (10,12,16).

PRP is the most extensively studied biologic for meniscal repair augmentation. A metaanalysis of five comparative trials reported a failure rate of 10 % with PRP versus 26% in controls, indicating a significant survival benefit (10). Another meta-analysis, however, does not demonstrate any difference in outcomes (166). Recent randomized trials demonstrated improved MRI-based healing and short-term functional scores with PRP use (167-169). However, other studies, particularly in specific tear types such as discoid lateral meniscus tears, have not shown significant benefit of PRP on PROs or failure rates (170-172). While PRP appears to improve meniscal healing in some contexts, the optimal formulation, delivery technique and patient selection criteria remain undefined (16).

The use of fibrin clots for meniscus augmentation was introduced in 1988 as a chemotactic matrix to promote healing in avascular zones (161). Preclinical studies support their role in attracting synovial cells and promoting vascularization, but clinical conclusions are difficult to determine because the population in these studies underwent concomitant ACLR (16,162,173). A previous study that combined fibrin clots with meniscal repair reported only 8% failures with fibrin clots versus 40% with repair alone in patients with isolated meniscus tears (162). However, other case series report mid-term success rates of 70–75 %, comparable to nonaugmented repairs (174,175). Limitations of the current literature include inconsistent clot preparation and lack of high quality comparative studies to provide firm conclusions (10,16). An example of fibrin clot augmentation may be seen in Figure 4.

Figure 4 Fibrin clot used in augmentation of meniscus repair.

Cell-based biologics are another promising strategy in meniscus augmentation and bone-marrow-derived MSCs have been the most studied source (12,16). Pre-clinical studies demonstrate that bone-marrow-derived MSCs survive and proliferate in avascular meniscal zones, increasing extracellularmatrix production and cellularity (176-180). A small clinical study reported improvement in three of five patients at 12 months, with stable results to 24 months, while two patients required meniscectomy (181). A prospective cohort using bonemarrow aspirate concentrate showed functional gains and a 12% failure rate, although a national database analysis found no clear superiority of bone-marrow-derived MSCs or PRP compared to controls in terms of revision rates (16,182,183).

Meniscus augmentation, whether using PRP, fibrin clot or MSCs, shows biological plausibility and early clinical signals of benefit. However, the evidence base is sparse, heterogeneous, and limited to low-level studies (10,12,16,162,167-169,173-175,184). Standardized outcome measures are necessary to determine the true efficacy and optimal protocols for these therapies (10,12,16).

Biologics in ligament augmentation

Biological augmentation in knee ligament reconstruction aims to accelerate graft healing, improve tendon-bone integration and reduce morbidity (185,186). PRP, with its supraphysiologic concentration of growth factors, has shown promising histologic and biomechanical improvements in pre-clinical models (187-189). A randomized trial looking at PRP use in ACLR report demonstrated PRP may enhance graft maturation on MRI, but other studies show that PRP does not reliably prevent tunnel widening or improve short-term functional scores (185). One such trial of 120 patients found that a protocol utilizing three postoperative PRP injections yielded no significant improvements in knee function, graft appearance, or stability at 12 months compared to reconstruction without PRP (190). Ultimately, variations in the literature, especially in PRP preparation and surgical technique, contribute to the mixed results and low overall quality of evidence (157,185).

Bone-marrow-derived MSCs have also been associated with promoting biological healing (158,186). In a largeanimal ovine model, both bone-marrow-derived MSCs and PRP significantly increased graft maturation scores compared with untreated controls (160). Other animal studies have examined MSC injections for partial ligament tear, demonstrating MRI evidence of regeneration in select cases (191,192). One randomized trial demonstrated improved graft revascularization at 3 months and higher International Knee Documentation Commitee (IKDC) scores at 9 months although this did not reach MCID (193). Limited human studies reported improved PROs and reduced jointspace narrowing after use with treatment of ACL injuries (194,195). Nevertheless, clinical human data remain limited and definitive conclusions on MSC use in ligament augmentation cannot be drawn.

Overall, biologic augmentation offers a plausible strategy for enhancing ligament graft incorporation. However, high quality literature and standardized trials are required to determine the clinical value of these therapies in ligament augmentation (158,186). A summary of biologic options for meniscus augmentation is listed in Table 3.

Conclusions

This review demonstrates that there is much room for improvement in outcomes for treatment of meniscus and ligament injuries of the knee. Improvements are needed to address failure of current techniques, strength and durability, and prevention of post-traumatic osteoarthritis. Technological advancements in augmentation with suture, scaffolds, allograft, and biologics may help offer much needed improvements. The current literature demonstrates promising short- and mid-term outcomes for many new technologies. As with any developing technology, further study is needed to determine long-term outcomes, compare to current gold-standard techniques, and refine appropriate surgical indications. Massive data combined with artificial intelligence may ultimately unlock many technologies. As current studies progress to provide longer-term data and new, high-quality, clinical studies commence, a comprehensive understanding of technologies such as augmentation, bioinductive scaffolds, and cell based treatments will be paramount in translating their potential into clinical benefits for patients.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Ting Cong) for the series “Current Concepts and Techniques in Soft Tissue Repair and Joint Preservation” published in Annals of Joint. The article has undergone external peer review.

Peer Review File: Available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-65/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-65/coif). The series “Current Concepts and Techniques in Soft Tissue Repair and Joint Preservation” was commissioned by the editorial office without any funding or sponsorship. V.M. declares receiving educational grants from National Center for Advancing Translational Sciences of the NIH [Grant/Award Number: TL1TR001858 (Training support for Poploski KM)] and Department of Defense STaR Trial (W81XWH-17-2-07); educational grants from Arthrex and DePuy/Synthes; consulting fees and speaking fees from Newclip and Smith & Nephew plc; and stock or stock options from Ostesys. He is a board member of ACL Study Group and the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS), and deputy editor-in-chief of Knee Surgery, Sports Traumatology, Arthroscopy (KSSTA), and has a patent, U.S. Patent No. 9,949,684, issued on April 24, 2018, to the University of Pittsburgh. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All clinical procedures described in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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