Dynamic intraligamentary stabilization

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The dynamic intraligamentary stabilization (DIS) is a surgical procedure for the treatment of a cruciate ligament rupture , which relies on a self-healing of the torn strip and stabilizes it by using a dynamic implant.

hypothesis

Histology of the cruciate ligament in a sheep model

While it is generally assumed that a torn cruciate ligament has no significant healing potential and therefore has to be replaced by a tendon transplant after a cruciate ligament rupture , Stefan Eggli postulated for the first time in 2005 that the cruciate ligament could be self-healing through stabilization.

After a cruciate ligament tear, the knee joint loses its rotational stability and, in particular, its forward translational stability of the lower leg. This instability means that certain sports that require a high degree of stability of the knee joint can no longer be practiced. In this case, surgery is the treatment of choice to correct this instability.

The cruciate ligament has two main functions: firstly, it stabilizes the knee joint, and secondly, thanks to the built-in mechanoreceptors ( Vater-Pacini bodies ) , it helps to control the muscular guidance of the knee joint. When a cruciate ligament ruptures, the knee loses not only part of its mechanical stability, but also part of its proprioception (deep sensitivity). Conventional cruciate ligament surgery can largely restore the mechanical stability of the knee joint - but not the deep sensitivity. On the one hand, this results in an increased risk of re-injury and, on the other hand, an increased risk of osteoarthritis.

With the dynamic intraligamentary stabilization the prerequisite is to be created that the own cruciate ligament can grow together again and thus the depth sensitivity is maintained. The self-healing of the cruciate ligament should reduce the risk of re-injury and the risk of osteoarthritis in the long term.

Animal model

Cruciate ligament reduction and stabilization using DIS

The dynamic intraligamentary stabilization was first tested on an animal model (sheep). The results were able to show that a cruciate ligament has healing potential.

In particular, the histological studies showed a rapid ingrowth of blood vessels into the torn portion of the ligament as well as retained deep receptors. In the biomechanical test, an increasing mechanical stability of the ligament could be measured, which is considered to be proof of the biological healing of a ligament.

Procedure

The dynamic intraligamental stabilization has been applied to ten patients for the first time in 2009. The results were successful, so that the procedure was used regularly from 2011.

Cruciate ligament tear and treatment with dynamic intraligamentary stabilization

Indication

Suitable for the cruciate ligament-retaining surgical technique are:

  • young patients
  • fresh crack (up to three weeks after the trauma, a crack should not be treated with this technique afterwards, as the healing potential decreases)
  • Tear in the upper third of the cruciate ligament (better chance of healing)
  • Additional injuries (menisci, collateral ligaments)
  • high demands on sport
Ligamys implant for dynamic intraligamentary stabilization

technology

The torn cruciate ligament is looped with absorbable sutures and repositioned at the anatomical point on the thigh. Then a screw is anchored in the lower leg with a spring system (Ligamys). A polyethylene thread is then placed behind the sewn cruciate ligament in the knee joint and attached to the thigh bone with a plate. This polyethylene thread is then pre-tensioned and fixed in the spring system with 80 Newtons so that the knee joint can be stabilized in any position. The sewn cruciate ligament thus receives the necessary rest and stability for healing. As the last step, microfracturing is performed at the tear-off point in the thigh area. As a result, stem cells and growth factors from the bone marrow of the thigh reach the tear zone of the cruciate ligament and stimulate the biological healing of the ligament.

Results

Clinical results from the first comparative studies and also from authors outside the research group have now been published. In terms of functional outcome and scores, they show results that are comparable to those of cruciate ligament surgery. Patients with dynamic stabilization have a higher level of activity immediately after surgery and return to work earlier than patients in whom the cruciate ligament has been replaced. After more than two years, the revision rate is 7.9–9.5%. Risk factors for a possible failure of this therapy method are: intermediate tears of the cruciate ligament, patients with competitive sport level (Tegner score> 5), a patient age under 24 years. Patient satisfaction with the procedure is high.

Individual evidence

  1. ^ Sandro Kohl, Dimitrios S. Evangelopoulos, Hendrik Kohlhof, Max Hartel, Harald Bonel: Anterior crucial ligament rupture: self-healing through dynamic intraligamentary stabilization technique . In: Knee Surgery, Sports Traumatology, Arthroscopy . tape 21 , no. 3 , March 23, 2012, p. 599-605 , doi : 10.1007 / s00167-012-1958-x .
  2. ^ Stefan Eggli, Hendrik Kohlhof, M. Zumstein, Philipp Henle, Max Hartel: Dynamic intraligamentary stabilization: novel technique for preserving the ruptured ACL . In: Knee Surgery, Sports Traumatology, Arthroscopy . tape 23 , no. 4 , March 21, 2014, p. 1215-1221 , doi : 10.1007 / s00167-014-2949-x , PMID 24651979 , PMC 4371814 (free full text).
  3. ↑ Benedikt Schliemann, Simon Lenschow, Christoph Domnick, Mirco Herbort, Janosch Häberli: Knee joint kinematics after dynamic intraligamentary stabilization: cadaveric study on a novel anterior cruciate ligament repair technique . In: Knee Surgery, Sports Traumatology, Arthroscopy . August 4, 2015, p. 1-7 , doi : 10.1007 / s00167-015-3735-0 .
  4. ↑ a b Bierbaum M. et al: Cost-utility analysis of dynamic intraligamentary stabilization versus early reconstruction after rupture of the anterior cruciate ligament. Health Econ Rev. 2017 Dec; 7 (1): 8. PMID 28168633 doi: 10.1186 / s13561-017-0143-9
  5. ↑ Bieri KS et al: Dynamic intraligamentary stabilization versus conventional ACL reconstruction: A matched study on return to work. Injury. 2017 Jun; 48 (6): 1243-1248. PMID 28318538 doi: 10.1016 / j.injury.2017.03.004
  6. ↑ Schliemann B. et al: Changes in gait pattern and early functional results after ACL repair are comparable to those of ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2017 Jul 3. PMID 28674740 doi: 10.1007 / s00167-017-4618-3
  7. ↑ a b Henle P. et al: Patient and surgical characteristics that affect revision risk in dynamic intraligamentary stabilization of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc. 2017 May 18. PMID 28523340 doi: 10.1007 / s00167-017-4574-y
  8. ↑ Krismer AM et al: Factors influencing the success of anterior cruciate ligament repair with dynamic intraligamentary stabilization. Knee Surg Sports Traumatol Arthrosc. 2017 Feb 17. PMID 28210790 doi: 10.1007 / s00167-017-4445-6
  9. ↑ Stefan Eggli, Christoph Röder, Gosia Perler, Philipp Henle: Five year results of the first ten ACL patients treated with dynamic intraligamentary stabilization . In: BMC Musculoskeletal Disorders . tape 17 , January 1, 2016, p. 105 , doi : 10.1186 / s12891-016-0961-7 , PMID 26920141 , PMC 4769577 (free full text).
  10. ↑ Philipp Henle, Christoph Röder, Gosia Perler, Sven Heitkemper, Stefan Eggli: Dynamic Intraligamentary Stabilization (DIS) for treatment of acute anterior cruciate ligament ruptures: case series experience of the first three years . In: BMC Musculoskeletal Disorders . tape 16 , January 1, 2015, p. 27 , doi : 10.1186 / s12891-015-0484-7 , PMID 25813910 , PMC 4341869 (free full text).