Regarding “Acute Proximal Anterior Cruciate Ligament Tears: Outcomes After Arthroscopic Suture Anchor Repair Versus Anatomic Single-Bundle Reconstruction”

Abstract

We would like to applaud Achtnich et al.1Achtnich A. Herbst E. Forkel P. et al.Acute proximal anterior cruciate ligament tears: Outcomes after arthroscopic suture anchor repair versus anatomic single-bundle reconstruction.Arthroscopy. 2016; 32: 2562-2569Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar on their recent work in Arthroscopy. The authors reported their 2-year outcomes of arthroscopic primary repair and compared this to the gold standard of single-bundle anterior cruciate ligament (ACL) reconstruction. We could not agree more that the concept of arthroscopic primary ACL repair of proximal avulsion type tears is ripe for further investigation. In their study, Achtnich et al.1Achtnich A. Herbst E. Forkel P. et al.Acute proximal anterior cruciate ligament tears: Outcomes after arthroscopic suture anchor repair versus anatomic single-bundle reconstruction.Arthroscopy. 2016; 32: 2562-2569Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar used a single locking stitch with one anchor to refixate the ACL to the femoral wall with additional microfracturing to improve healing. Previously, we described our early results in the first 11 patients treated with arthroscopic suture anchor primary repair for proximal avulsion tears.2DiFelice G.S. Villegas C. Taylor S. Anterior cruciate ligament preservation: Early results of a novel arthroscopic technique for suture anchor primary anterior cruciate ligament repair.Arthroscopy. 2015; 31: 2162-2171Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar Our approach used 2 sutures that were placed into each bundle, after which these bundle sutures were tensioned and fixed to the femoral wall using two 4.75-mm vented BioComposite SwiveLock anchors.3DiFelice G.S. van der List J.P. Arthroscopic primary repair of proximal anterior cruciate ligament tears.Arthrosc Tech. 2016; 5: e1057-e1061Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Our reasoning is to create an anatomic reapproximation of both native ACL bundles (Fig 1) to their respective femoral footprints, as this maximizes the ligament-bone contact area and creates a more anatomic and theoretically more biomechanical construct because both bundles have unique biomechanical contributions to knee stability.4Zantop T. Herbort M. Raschke M.J. Fu F.H. Petersen W. The role of the anteromedial and posterolateral bundles of the anterior cruciate ligament in anterior tibial translation and internal rotation.Am J Sports Med. 2007; 35: 223-227Crossref PubMed Scopus (374) Google Scholar In a recent biomechanical study, this 2-anchor construct was indeed shown to be strong enough to allow early motion without fear of gap formation.5van der List JP, DiFelice GS. Gap formation following primary repair of the anterior cruciate ligament: A biomechanical evaluation [published online December 7, 2016]. Knee. doi:10.1016/j.knee.2016.10.009.Google Scholar In addition, the vented nature of the suture anchors accomplishes the same goal as microfracturing, that is enhancing ligament healing. Furthermore, the described technique uses a single locking stitch placed at the midsubstance of the ligament, whereas with our technique, suturing begins distally and creates an alternating, interlocking Bunnell-type stitch that exits the proximal end (Fig 2). This provides increased stiffness to the repair construct and also restores the femoral attachment more anatomically. Having now performed proximal repairs in more than 75 patients, it has been noted that starting suturing distally provides more secure purchase into the ligament remnant, and also allows the repair of proximal tears with suboptimal tissue quality. Finally, the reported concern of ligament strangulation has not been found to be an issue with our technique. Attention should be paid not to wrap the sutures around the ligament, but to crisscross them to minimize strangulation risk and suture bulk. In an editorial in Arthroscopy, Hohmann6Hohmann E. Editorial Commentary: Renaissance of primary anterior cruciate ligament repair: Is history repeating itself?.Arthroscopy. 2016; 32: 2570-2571Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar rightfully pointed out that the reported 15% failure rate is notable. However, it is important to also consider the morbidity of both procedures. In our experience, repair patients have a dramatically faster and easier recovery with fewer complications compared with reconstruction patients. Moreover, the 15% failed repair patients can undergo a “revision” that is more like a primary reconstruction, while revision of ACL reconstruction has several limitations.7Lind M. Menhert F. Pedersen A.B. Incidence and outcome after revision anterior cruciate ligament reconstruction: results from the Danish registry for knee ligament reconstructions.Am J Sports Med. 2012; 40: 1551-1557Crossref PubMed Scopus (240) Google Scholar, 8Lefevre N. Klouche S. Mirouse G. Herman S. Gerometta A. Bohu Y. Return to sport after primary and revision anterior cruciate ligament reconstruction.Am J Sports Med. 2017; 45: 34-41Crossref PubMed Scopus (92) Google Scholar, 9Kamath G.V. Redfern J.C. Greis P.E. Burks R.T. Revision anterior cruciate ligament reconstruction.Am J Sports Med. 2011; 39: 199-217Crossref PubMed Scopus (221) Google Scholar We believe these factors, in addition to the failure rate, should be taken into account when evaluating the outcomes of primary repair versus reconstruction.10van der List J.P. DiFelice G.S. Preservation of the anterior cruciate ligament: A treatment algorithm based on tear location and tissue quality.Am J Orthop (Belle Mead NJ). 2016; 45: E393-E405PubMed Google Scholar, 11van der List JP, DiFelice GS. Primary repair of the anterior cruciate ligament: A paradigm shift [published online October 6, 2016]. Surgeon. doi:10.1016/j.surge.2016.09.006.Google Scholar We agree with the authors that arthroscopic primary ACL repair is an excellent treatment option for selected patients. Although further research into this exciting topic is clearly warranted, it is obvious that this is only the beginning of the conversation. Editorial Commentary: Renaissance of Primary Anterior Cruciate Ligament Repair: Is History Repeating Itself?ArthroscopyVol. 32Issue 12PreviewIn a comparative Level III study, Achtnich et al. compared suture anchor repair of acute proximal anterior cruciate ligament avulsion tears with single-bundle anterior cruciate ligament reconstruction with the quadrupled semitendinosus tendon. Short-term follow-up at a mean of 28 months showed that the between-group differences were not different. These results are encouraging but not different from other published series 25+ years ago. Only time will tell whether the long-term outcomes are identical and whether these techniques will also die a slow death. Full-Text PDF Anterior Cruciate Ligament Preservation: Early Results of a Novel Arthroscopic Technique for Suture Anchor Primary Anterior Cruciate Ligament RepairArthroscopyVol. 31Issue 11PreviewTo propose a technique of arthroscopic suture anchor primary anterior cruciate ligament (ACL) preservation for patients with proximal avulsion ACL tears that maintain excellent tissue quality. Full-Text PDF Acute Proximal Anterior Cruciate Ligament Tears: Outcomes After Arthroscopic Suture Anchor Repair Versus Anatomic Single-Bundle ReconstructionArthroscopyVol. 32Issue 12PreviewTo compare clinical and radiologic results of primary anterior cruciate ligament (ACL) suture anchor repair and microfracturing with anatomic ACL single-bundle reconstruction in patients with acute proximal ACL avulsion tears. Full-Text PDF Arthroscopic Primary Repair of Proximal Anterior Cruciate Ligament TearsArthroscopy TechniquesVol. 5Issue 5PreviewIn a select group of patients with proximal anterior cruciate ligament (ACL) tears, primary repair can be a useful technique. Preservation of the native ACL may be advantageous for proprioceptive function and is thought to restore normal knee joint kinematics. The procedure is a less morbid and more conservative surgical approach to restore knee stability. Primary repair is preferably performed in the acute setting because of better healing capacity and tissue quality. We present the surgical technique of arthroscopic primary ACL repair with suture anchors in patients with proximal tears and excellent tissue quality. Full-Text PDF Open AccessAuthors' ReplyArthroscopyVol. 33Issue 4PreviewWe thank van der List and DiFelice for their valuable comments regarding our article on the outcome of anterior cruciate ligament (ACL) repair surgery published in Arthroscopy.1 We agree with them and we are convinced that with the right indications, primary ACL repair can be performed in a subset of patients, and, therefore, the aim of our study was to draw the clinician's awareness to this important topic. Full-Text PDF