Successful Arthroscopic Primary Repair of a Chronic Anterior Cruciate Ligament Tear 11Years Following Injury.

Abstract

Approximately 120 years ago, Mayo Robson performed the first treatment of an anterior cruciate ligament (ACL) injury using open primary repair of a proximal ACL and posterior cruciate ligament (PCL) tear [26]. Over the ensuing decades, the surgical treatment of primary ACL repair was further popularized by Palmer in the 1930s and 1940s [24] and O’Donoghue in the 1950s and 1960s [20–22] and, initially, the short-term results of open primary ACL repair were excellent [15, 17, 29]. It was, however, noted that the outcomes of open primary ACL repair deteriorated with time and were considered to be unpredictable at mid-term follow-up [6, 7, 13, 15, 21, 30]. A possible explanation for these unpredictable results followed in 1991, when Sherman et al. reported an extensive subgroup analysis of primary ACL repair outcomes and found that better results were associated with proximal tears and excellent tissue quality. Several other studies also noted better results in the subset of patients with proximal tears [9, 11, 14, 23, 37]. Other factors that could have contributed to these mixed results were invasive surgery (i.e., arthrotomy) and the postoperative regimen (i.e., immobilization for 6 weeks) [18]. Modern developments such as magnetic resonance imaging (MRI), arthroscopic surgery, and early postoperative motion protocols enable better patient selection, less invasive treatment, and more optimal postoperative management. Not surprisingly, a recent case series of arthroscopically repaired proximal ACL tears has reported excellent results [5], and it seems that there is a recent resurgence of interest in primary ACL repair [1, 4, 31, 34]. Several advantages of ACL preservation with primary repair exist, when compared to ACL reconstruction, including maintaining proprioceptive function [25, 28] and the native ACL kinematics [27]. Traditionally, treatment of primary ACL repair was performed in the acute setting [2, 20–22, 36] as it was advocated that “in all types of injury early repair (under two weeks) gives much better results than late repair or reconstruction” [21]. It was thought that performing repair in the acute setting provided optimal tissue quality and prevented ligament retraction and/or reabsorption [2, 21, 22, 36]. Therefore, primary ACL repair was not performed in the non-acute setting as surgeons tended to prefer ACL reconstruction under these circumstances. Not surprisingly, no studies or cases of performing ACL repair in the non-acute setting could be found when reviewing the literature. Therefore, we would like to present a case of successful arthroscopic primary repair of a chronic ACL tear in a 38-year-old male.