Anterior Cruciate Ligament Repair Research Articles

Acute anterior cruciate ligament rupture: can repair become an alternative to reconstruction: a meta-analysis of randomized controlled trials and cohort studies.

To perform a meta-analysis to compare clinical outcomes of anterior cruciate ligament (ACL) repair and ACL reconstruction for acute ACL rupture. We searched Pubmed, Embase, the Cochrane Library, and Web of Science databases to seek relevant studies. Clinical outcomes included failure rate, hardware removal rate, anteroposterior (AP) knee laxity, and patient-reported outcomes. In addition, subgroup analysis was carried out according to repair techniques, rupture locations, and study designs. Funnel plots were used to detect publication bias. All statistical analysis was performed using STATA (version 14.2, StataCorp). A total of 10 articles were included in this study, comprising 5 randomized controlled trials (RCTs) and 5 cohort studies, involving a total of 549 patients. We found no statistical differences between the ACL repair and ACL reconstruction in the following outcomes: failure rate, AP knee laxity, International Knee Documentation Committee (IKDC) score, Lysholm score, Knee Injury and Osteoarthritis Outcome (KOOS) Score, and Tegner score. However, the ACL repair group had a higher hardware removal rate. Except for AP knee laxity results on different repair techniques, there was no statistical difference in other subgroup analyses. Compared with ACL reconstruction, ACL repair shows similar results in clinical outcomes, and it is promising to be an effective alternative treatment for acute ACL rupture. Larger samples and higher-quality studies are needed to support our results and further explore the advantages of ACL repair in other aspects. Level III.

Management of Meniscus Pathology with Concomitant Anterior Cruciate Ligament Injury.

The purpose of this review is to summarize current clinical knowledge on the prevalence and types of meniscus pathology seen with concomitant anterior cruciate ligament (ACL) injury, as well as surgical techniques, clinical outcomes, and rehabilitation following operative management of these pathologies. Meniscus pathology with concomitant ACL injury is relatively common, with reports of meniscus pathology identified in 21-64% of operative ACL injuries. These concomitant injuries have been associated with increased age and body mass index. Lateral meniscus pathology is more common in acute ACL injury, while medial meniscus pathology is more typical in chronic ACL deficiency. Meniscus tear patterns associated with concomitant ACL injury include meniscus root tears, lateral meniscus oblique radial tears of the posterior horn (14%), and ramp lesions of the medial meniscus (8-24%). These meniscal pathologies with concomitant ACL injury are associated with increased rotational laxity and meniscal extrusion. There is a paucity of comparative studies to determine the optimal meniscus repair technique, as well as rehabilitation protocol, depending on specific tear pattern, location, and ACL reconstruction technique. There has been a substantial increase in recent publications demonstrating the importance of meniscus repair at the time of ACL repair or reconstruction to restore knee biomechanics and reduce the risk of progressive osteoarthritic degeneration. Through these studies, there has been a growing understanding of the meniscus tear patterns commonly identified or nearly missed during ACL reconstruction. Surgical management of meniscal pathology with concomitant ACL injury implements the same principles as utilized in the setting of isolated meniscus repair alone: anatomic reduction, biologic preparation and augmentation, and circumferential compression. Advances in repair techniques have demonstrated promising clinical outcomes, and the ability to restore and preserve the meniscus in pathologies previously deemed irreparable. Further research to determine the optimal surgical technique for specific tear patterns, as well as rehabilitation protocols for meniscus pathology with concomitant ACL injury, is warranted.

Enhancing tendon-bone integration and healing with advanced multi-layer nanofiber-reinforced 3D scaffolds for acellular tendon complexes

Advancements in tissue engineering are crucial for successfully healing tendon-bone connections, especially in situations like anterior cruciate ligament (ACL) restoration. This study presents a new and innovative three-dimensional scaffold, reinforced with nanofibers, that is specifically intended for acellular tendon complexes. The scaffold consists of a distinct layered arrangement comprising an acellular tendon core, a middle layer of polyurethane/type I collagen (PU/Col I) yarn, and an outside layer of poly (L-lactic acid)/bioactive glass (PLLA/BG) nanofiber membrane. Every layer is designed to fulfill specific yet harmonious purposes. The acellular tendon core is a solid structural base and a favorable environment for tendon cell functions, resulting in considerable tensile strength. The central PU/Col I yarn layer is vital in promoting the tendinogenic differentiation of stem cells derived from tendons and increasing the expression of critical tendinogenic factors. The external PLLA/BG nanofiber membrane fosters the process of bone marrow mesenchymal stem cells differentiating into bone cells and enhances the expression of markers associated with bone formation. Our scaffold's biocompatibility and multi-functional design were confirmed through extensive in vivo evaluations, such as histological staining and biomechanical analyses. These assessments combined showed notable enhancements in ACL repair and healing. This study emphasizes the promise of multi-layered nanofiber scaffolds in orthopedic tissue engineering and also introduces new possibilities for the creation of improved materials for regenerating the tendon-bone interface.

Rate of Revision Surgery and Associated Risk Factors After Primary Arthroscopic ACL Repair With Additional Suture Augmentation.

Recent studies have suggested promising patient-reported outcomes after primary anterior cruciate ligament (ACL) repair with additional suture augmentation (SA). To evaluate the risk for revision surgery and identify patient- and injury-related risk factors after ACL repair with SA in a large patient cohort subject to strict patient selection. Case-control study; Level of evidence, 3. Included were 86 patients (61 female; 93% follow-up rate) who underwent arthroscopic ACL repair with SA between January 2017 and March 2019 by a single surgeon and had a minimum follow-up of 24 months. Patients were selected for surgery with regard to time to surgery (preferably on the day of injury), tear pattern (limited to Sherman types 1 and 2), and tissue quality (intact synovial coverage). Postoperatively, the patients who needed revision surgery were identified and compared with patients who did not undergo revision surgery, using the Mann-Whitney U test for nonparametric analysis and the Student t test for parametric analysis. A Kaplan-Meier analysis was performed to investigate the survival rate of the ACL repair. A total of 9 patients (10%; median age, 48 years; interquartile range [IQR], 27-50 years) underwent revision surgery at 12 months postoperatively (IQR, 8-25 months). The median follow-up of patients without revision surgery was 35 months (IQR, 33-44 months). The revision-free survival rate was 97% (95% CI, 93%-100%) after 1 year, 93% (95% CI, 88%-98%) after 2 years, and 90% (95% CI, 83%-97%) after 4 years. Patient-related factors-such as sex (P = .98), age at surgery (P = .459), body mass index (P = .352), and preinjury level of sports (P = .53)-had no significant impact on the survival rate of the ACL repair. Injury-related factors-such as concomitant injuries of the medial (P = .860) and lateral menisci (P = .414) and the medial (P = .801) and lateral collateral ligaments (P = .534) or same-day surgery compared with a delay of surgery of up to 18 days (P = .277)-had no significant impact on the survival rate of the ACL repair. The revision rate of primary ACL repair with SA at a 2-year follow-up was 10%. Patient- and injury-related factors were not associated with the survival rate of the ACL repair.

Bridge-Enhanced Anterior Cruciate Ligament Restoration: Surgical Technique

Background: Anterior cruciate ligament (ACL) repair has historically had poor outcomes and fell out of favor in the 1980s with the majority of surgeons opting to do an ACL reconstruction instead due to the high failure rate. The Bridge-Enhanced ACL Restoration or BEAR technique utilizes a de-cellularized, bovine-derived, type I collagen implant to aid in the ACL repair. The device is implanted to augment the healing of the ACL. Indications: The BEAR technique is indicated to augment ACL repair in cases of complete rupture where there is a residual tibial stump of sufficient length and good tissue quality. Results: In our experience to date, patients undergoing an ACL repair with BEAR recover range of motion quickly and have less quadriceps atrophy and less postoperative swelling than those undergoing ACL reconstruction requiring autograft harvest. We will continue to follow up our patient cohort to assess for re-rupture rate as they return to sport. Conclusion: The BEAR technique is a promising development that enables ACL repair as an alternative option to reconstruction. This article describes our approach including tips and tricks to successfully perform this procedure. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form.

Outcomes of Primary Anterior Cruciate Ligament (ACL) Repair for Proximal Tears: A Systematic Review and Meta-Analysis.

The purpose of this study is to compare failure rates among different techniques of primary anterior cruciate ligament (ACL) repair for the treatment of proximal ACL ruptures. Meta-analysis and systematic review were completed, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA) guidelines were followed. Studies from Embase, Cochrane, and PubMed published between June 2011 and June 2022 reporting outcomes of primary ACL repair on proximal tears with a minimum two-year follow-up were included. Primary ACL repair was divided into dynamic, static, and non-augmented repair. The primary outcome was failure rates, and the secondary outcomes included patient-reported outcomes (PROs) and anterior tibial stability (ATT). Eighteen studies on primary ACL repair were included, with a total of 614 patients (ages rangingfrom 6 to 65, 60% male). Only two studies were level 1 randomized controlled clinical trials. The static repair had a failure rate of 33 out of 261 (12.6%), non-augmented was 17 out of 179 (9.4%), and dynamic repair was 31 out of 174 (17.8%); no statistically significant difference was found comparing the failure rates (p = 0.090). PROs using the International Knee Documentation Committee (IKDC) and Lysholm scores had weighted averages of 91.7 (95% confidence interval (CI): 89.6-93.8) and 94.7 (95% CI: 92.7-96.7), respectively. ATT had a weighted average of 1.668 mm (95% CI: 1.002-2.334). The primary findings of this paper include a 12.6% combined failure rate for primary proximal ACL repair with no significant difference in failure rate or PROs when accounting for the methodology of repair at a minimum two-year follow-up. It is important to note the lack of high-quality randomized controlled trials, the heterogeneity of included studies, and the lack of long-term data. Despite these limitations, the findings of the current analysis suggest that primary repair may be a useful treatment option for indicated candidates with proximal ACL ruptures. Further long-term and higher-quality comparative studies on ACL reconstruction are warranted.

Peripheral Nerve Stimulation in Postoperative Analgesia: A Narrative Review.

Recent research has shown the effectiveness of peripheral nerve stimulators (PNS) in managing chronic pain conditions. Ongoing studies aim to explore its potential application in treating acute postoperative pain states. The purpose of this systematic review is to assess the role of PNS in providing relief for postoperative pain. Clinical studies investigating the use of peripheral nerve stimulators (PNS) for analgesia following various surgeries, such as total knee arthroplasty, anterior cruciate ligament repair, ankle arthroplasty, rotator cuff repair, hallux valgus correction, and extremity amputation, have shown promising results. Lead placement locations include the brachial plexus, sciatic, femoral, tibial, genicular, perineal, sural, radial, median, and ulnar nerves. These studies consistently report clinically significant reductions in pain scores, and some even indicate a decrease in opioid consumption following PNS for postoperative pain. PNS involves the subcutaneous placement of electrode leads to target peripheral nerve(s) followed by delivery of an electric current via an external pulse generator. While the precise mechanism is not fully understood, the theory posits that PNS modulates electrical stimulation, hindering the signaling of nociceptive pain. PNS presents itself as an alternative to opioid therapy, holding promise to address the opioid epidemic by offering a nonpharmacologic approach for both acute and chronic pain states.

Arthroscopic repair of proximal anterior cruciate ligament tears in children and adolescents: A systematic review.

Anterior cruciate ligament repair techniques are of growing interest because they allow for minimally invasive surgery that avoids harvesting of the transplant, without risking growth deficiencies in young patients. The aim of this study is to summarize the published evidence about arthroscopic repair of anterior cruciate ligament proximal tears in skeletally immature patients. In total, four studies were included and processed for data extraction after screening for eligibility for this systematic review: one retrospective cohort study and three retrospective case series. Altogether, the four studies included in this review included 61 skeletally immature patients with a mean age of 12.1 years diagnosed with proximal anterior cruciate ligament tear who underwent arthroscopic repair with preservation of the native ligament. The mean follow-up period was 2.8 years. The most relevant and objective outcome that we considered was re-rupture rate. One study reports a cumulative incidence of graft failure in the first 3 years after surgery of 48.8% while the others report a 0%, 0% and 21.5% re-rupture rate. No growth disturbances were reported in the included studies. Despite growing interest surrounding anterior cruciate ligament repair techniques, the presence of limited quality studies in the literature means repair cannot be strongly supported at present. Some encouraging data regarding the absence of growth disturbance and functional outcomes does exist, but studies with larger samples are required. level IV.

Advancements in Anterior Cruciate Ligament Repair—Current State of the Art

While anterior cruciate ligament reconstruction (ACL-R) has been considered the gold standard for ACL tears, renewed interest in ACL repair has emerged. This review aims to examine the current knowledge regarding ACL repair. A comprehensive literature search was conducted on the PubMed, Web of Science, Scopus, and Embase databases, focusing on the most recent studies up to January 2024. Arthroscopic ACL repair has several advantages, such as resulting in a natural ligament with proprioceptive properties, preservation, and donor graft comorbidity absence. Several ACL repair surgical procedures have been developed thanks to the advancement in new fixation devices. The current literature showed that when performed on a suitable patient with the appropriate lesion type, corresponding to the proximal third with good tissue quality, ACL repair leads to satisfactory outcomes. Despite the benefits of ACL repair with promising results, ACL-R remains the gold standard for ACL lesions. There is still a lack of literature analyzing long-term outcomes; large series with homogenous populations and types of lesions are lacking. Based on the current evidence, further research and higher-quality studies investigating ACL repair will be necessary.

Principles for optimizing anterior cruciate ligament reconstruction outcomes in elite athletes: a review of current techniques.

Anterior cruciate ligament (ACL) tears are one of the most common sport-related injuries and occur in greater than 3% of athletes in a four-year window of sports participation. Non-contact injuries are the most common mechanism for ACL injury in elite-level athletes, especially with increased valgus and external rotation of the knee when loading eccentrically in flexion. Because of the immense toll these injuries and their recovery take on athletes especially, optimal treatment has been a subject of great interest for some time. Many ACL reconstruction (ACLR) and repair techniques have been implemented and improved in the last two decades, leading to many surgical options for this type of injury. The surgical approach to high-level athletes in particular requires additional attention that may not be necessary in the general population. Important considerations for optimizing ACL treatment in high-level athletes include choosing repair vs. reconstruction, surgical techniques, choice of auto- or allograft, and associated concomitant procedures including other injuries or reinforcing techniques as well as attention to rehabilitation. Here, we discuss a range of surgical techniques from repair to reconstruction, and compare and contrast various reconstructive and reinforcing techniques as well as associated surgical pearls and pitfalls. Good outcomes for athletes suffering from ACL injury are attainable with proper treatment including the principles discussed herein.

Conservative vs Surgical Treatment of Anterior Cruciate Ligament Rupture: A Systematic Review.

Anterior cruciate ligament (ACL) injury is very common, especially in young athletic individuals who injure themselves during sports involving pivoting actions. Management options include conservative management, which involves progressive physical therapy, educating the patient on how to prevent instability, and the use of a hinged knee brace. Surgical management involves reconstruction of the torn ligament using an autograft or an allograft and ACL repair where the torn ligament is affixed back to the tibia or femur.The choice of management depends on the severity of the injury, other injuries in associated structures, the level of fitness, and the athletic goals of the patient. Many studies exist on the management choice of ACL injury, but no clear consensus prevails. This study will examine the effectiveness of conservative versus surgical management. A literature review will be performed to identify appropriate papers which compare and evaluate the two approaches. A literature search for randomized controlled trials (RCTs) and cohort studies comparing the conservative to surgical management of ACL injury was conducted on PubMed, Scopus, and Web of Science. Patient eligibility criteria included individuals older than 15 with an isolated, recent ACL injury diagnosis via an appropriate clinical test, MRI, or arthroscopy. Studies were eligible if they were using appropriate surgical or conservative methods, as mentioned previously, and measuring results via appropriate scores, tools, and methods that will be presented below. The follow-up timeline would be from presentation time until at least two years. Five papers were found to be eligible. Overall, these papers included 462 patients. Two studies measuring overall knee symptoms, function, and sports activities using the International Knee Documentation Committee Subjective Knee Form (IKDC) score found that the operated group had a significantly higher score. The other two studies measured overall knee function and health using the Tegner & Lysholm and Knee Injury and Osteoarthritis Outcome Score (KOOS) scores. In both papers, no significant difference was found between the two groups. Regarding Tegner's activity score, only one paper had significant findings. A significantly longer period to return to sports activities was observed in the operative group. Stability was significantly higher in all papers in the operated group. Osteoarthritis was measured using different tools in each paper. Only one paper found a significantly higher risk in the operated group. Only one paper indicated significantly more complications in the operated group regarding side effects. Overall, very few differences were observed between the two treatment groups. The most significant differences observed were the higher stability and the longer recovery period in patients undergoing surgery. Large RCTs following patients for enough time are needed to prove if surgical treatment offers significant benefits over conservative treatment.

The minimum effective concentration (MEC90) of bupivacaine for an ultrasound-guided suprainguinal fascia iliaca compartment block for analgesia in knee surgery: a dose-finding study.

In recent years, the suprainguinal fascia iliaca compartment block (SFICB) has become more common in clinical practice. This assessor-blinded dose-finding study aimed to determine the minimum effective concentration (MEC90, MEC95) of bupivacaine for a single-injection SFICB in patients undergoing arthroscopic anterior cruciate ligament repair. This prospective study was conducted at a tertiary hospital (postoperative recovery room and ward). The SFICB was performed as a postsurgical intervention after spinal anesthesia. Seventy patients were allocated using the biased-coin design up-and-down sequential method. The ultrasound-guided SFICB was performed using different bupivacaine concentrations, and standard multimodal analgesia was administered to all patients. Block success was defined as the absence of pain or presence of only tactile sensation during the pinprick test conducted on the anterior and lateral regions of the mid-thigh six hours postoperatively. According to isotonic regression and bootstrap CIs, the MEC90 value of bupivacaine for a successful SFICB was 0.123% (95% CI [0.098, 0.191]) and the MEC95 value was 0.188% (95% CI [0.113, 0.223]). Our study showed that the MEC90 and MEC95 values for bupivacaine administered via an SFICB for analgesia were 0.123% and 0.188%, respectively. One advantage of using lower concentrations of bupivacaine is the associated reduction in quadriceps weakness.

Primary anterior cruciate ligament repair-morphological and quantitative assessment by 7-T MRI and clinical outcome after 1.5 years.

The purpose of this study was to assess morphological and quantitative changes of the anterior cruciate ligament (ACL) and cartilage after ACL repair. 7T MRI of the knee was acquired in 31 patients 1.5 years after ACL repair and in 13 controls. Proton density-weighted images with fat saturation (PD-fs) were acquired to assess ACL width, signal intensity, elongation, and fraying. T2/T2* mapping was performed for assessment of ACL and cartilage. Segmentation of the ACL, femoral, and tibial cartilage was carried out at 12 ROIs. The outcome evaluation consisted of the Lysholm Knee Score and International Knee Documentation Committee (IKDC) subjective score and clinical examination. ACL showed a normal signal intensity in 96.8% and an increased width in 76.5% after repair. Fraying occurred in 22.6% without having an impact on the clinical outcome (Lysholm score: 90.39 ± 9.75, p= 0.76 compared to controls). T2 analysis of the ACL revealed no difference between patients and controls (p= 0.74). Compared to controls, assessment of the femoral and tibial cartilage showed a significant increase of T2* times in all ROIs, except at the posterolateral femur. Patients presented a good outcome in clinical examination with a Lysholm score of 87.19 ± 14.89 and IKDC of 80.23 ± 16.84. T2 mapping results suggest that the tissue composition of the ACL after repair is similar to that of a native ACL after surgery, whereas the ACL exhibits an increased width. Fraying of the ACL can occur without having any impact on functional outcomes. T2* analysis revealed early degradation at the cartilage. MRI represents a noninvasive diagnostic tool for the morphological and compositional assessment of the anterior cruciate ligament after repair, whereas knowledge about post-surgical alterations is crucial for adequate imaging interpretation. • There has been renewed interest in repairing the anterior cruciate ligament with a proximally torn ligament. • T2 times of the anterior cruciate ligament do not differ between anterior cruciate ligament repair patients and controls. • T2 mapping may serve as a surrogate for the evaluation of the anterior cruciate ligament after repair.

Comprehensive evaluation of magnetic resonance imaging sequences for signal intensity based assessment of anterior cruciate ligament healing following surgical treatment.

Normalized signal intensity (SI) obtained from magnetic resonance imaging (MRI) has been used to track anterior cruciate ligament (ACL) postoperative remodeling. We aimed to assess the effect of MRI sequence (PD: proton density-weighted; T2: T2-weighted; CISS: constructive interference in steady state) on postoperative changes in healing ACLs/grafts. We hypothesized that CISS is better at detecting longitudinal SI and texture changes of the healing ACL/graft compared to the common clinical sequences (PD and T2). MR images of patients who underwent ACL surgery were evaluated and separated into groups based on surgical procedure (Bridge-Enhanced ACL Repair (BEAR; n = 50) versus ACL reconstruction (ACLR; n = 24)). CISS images showed decreasing SI across all timepoints in both the BEAR and ACLR groups (p < 0.01), PD and T2 images showed decreasing SI in the 6-to-12- and 12-to-24-month postoperative timeframes in the BEAR group (p < 0.02), and PD images additionally showed decreasing SI between 6- and 24-months postoperation in the ACLR group (p = 0.02). CISS images showed texture changes in both the BEAR and ACLR groups, showing increases in energy and decreases in entropy in the 6-to-12- and 6-to-24-month postoperative timeframes in the BEAR group (p 0.04), and increases in energy, decreases in entropy, and increases in homogeneity between 6 and 24 months postoperation in the ACLR group (p < 0.04). PD images showed increases in energy and decreases in entropy between 6- and 24-months postoperation in the ACLR group (p < 0.008). Finally, CISS was estimated to require a smaller sample size than PD and T2 to detect SI differences related to postoperative remodeling.

Comparative results of subjective assessment by professional athletes of the functional state of the knee joint after anterior cruciate ligament repair with semitendinosus and gracillis tendons or peroneus longus tendon grafts

Aim: to evaluate the subjective functional state of the knee joint in professional athletes after arthroscopic reconstruction of the anterior cruciate ligament depending on the type of the autograft.Materials and methods: the study included 37 professional athletes, divided into 2 groups. Athletes of the first group underwent arthroscopic ACL reconstruction using hamstring tendon autograft, i. e. semitendinosus and gracillis tendons (ST/GR group). Athletes of the second group underwent reconstruction using peroneus longus autograft (PL group). For subjective evaluation IKDC, Lysholm and Cincinnati questionnaires were used. The significance of differences was assessed using the Mann — Whitney test. Differences were considered significant at p &lt; 0.05.Results: according to the Cincinnati questionnaire, the median scores of athletes from the ST/GR group was 96.0 points, from the PL group — 100.0 points (Me [Q1; Q3]: 96.0 [91.0; 100.0] and 100.0 [92.3; 100.0], respectively). According to the criteria of the rating scale, the median Lysholm score in points in the ST/GR group was 95.0, and in the PL group — 97.5 points (Me [Q1; Q3]: 95.0 [90.0;100.0] and 97.5 [92.0;100.0], respectively). According to IKDC measurements, the median score in the ST/GR group was 90.8, and in the PL group — 95.4 (Me [Q1; Q3]: 90.8 [81.0; 94.3] and 95.4 [89.1; 98.5], respectively.Conclusion: peroneus longus tendon autograft can be used for ACL reconstruction in professional athletes.

Functional and Psychological Preparedness of Athletes Post ACL Repair.

This study was conducted to see whether those who had anterior cruciate ligament (ACL) reconstructions on their dominant legs performed better than those who had them on their nondominant legs 1-10 years after the surgery. An examination of people who sustained injuries to their dominant (n = 25) and nondominant (n = 25) legs between 1 and 10 years after ACL repair was undertaken in a cross-sectional research with 50 people aged 20-38. Everyone takes the fear avoidance belief questionnaire for physical activity (FABQ-PA), the lower extremity functional scale (LEFS), and the anterior cruciate ligament return to sport after injury (ACL-RSI) survey. There was no statistically significant difference between the groups on the ACL-RSI, LEFS, and FABQ-PA (U = 254, P = 0.26; U = 314.4, P = 0.95; and U = 279.4, P = 0.53 correspondingly). Functional performance and patient mental health should be evaluated 1-10 years after ACL surgery. However, there is no correlation between which leg was the dominant one and the results. As a result, it has been shown that both dominant and nondominant leg injuries heal similarly over time. Future studies should examine additional variables that affect healing and return-to-sport results to improve rehabilitation and optimize long-term functional outcomes for individuals after ACL repair.

Reconstruction vs. repair: a review of recent trends and controversies for management of ACL rupture

Anterior cruciate ligament (ACL) repair has become increasingly popular in recent years as an option for management of ACL rupture. Though arthroscopic reconstruction has long been the gold standard, there may be a role for repair in appropriately selected patient populations and tear patterns. Recent industry-driven advances in techniques and available instrumentation for ACL repair have regenerated interest. Proponents of ACL repair highlight the maintenance of native tissues allowing for retained proprioception, lack of need for graft usage or harvest, and the potential for accelerated rehabilitation postoperatively as compared to ACL reconstruction. Short-term and early mid-term ACL repair studies have demonstrated encouraging results; however, the authors remain in favor of ACL reconstruction at this time given a dearth of long-term outcomes following ACL repair.

Suture Anchor Technique for Bridge Enhanced Anterior Cruciate Ligament Restoration

Anterior cruciate ligament (ACL) injuries are common in the athletic population. ACL repair with bridge enhancement is an emerging technology with promising clinical outcomes in patients with a proximal to midsubstance ACL tears. Currently, there are a variety of fixation methods described for isolated ACL repair, including suspensory and anchor techniques. This Technical Note describes a bridge enhanced ACL restoration procedure technique, using suture anchors for the femoral fixation. Advantages of this technique include more rigid fixation and avoiding need for accessory over-the-top incision. Additionally, the surgical workflow is more similar to an ACL reconstruction with intra-articular screw fixation, which may be more readily adopted by some surgeons.

An Isolated Midsubstance ACL Tear Repaired With the BEAR System

Background: Anterior cruciate ligament (ACL) repairs, once widely abandoned due to historically high failure rates, have recently regained interest with the development of the bridge-enhanced ACL repair (BEAR) implant, a novel arthroscopic technique that uses a resorbable protein-based implant combined with autologous blood to primarily repair a midsubstance ACL tear. This technical note presents a step-by-step surgical method for performing an isolated midsubstance ACL repair using the BEAR implant. Indications: The BEAR implant is indicated for skeletally mature patients at least 14 years of age with a complete rupture of the ACL, confirmed by magnetic resonance imaging. The complete ACL tear must have an attached stump to the tibia. Technique Description: A diagnostic arthroscopy is used to confirm complete rupture of the ACL and presence of residual tibial stump. A self-retrieving suture passage device is used to whipstitch a total of 6 passes with #2 Vicryl suture from distal to proximal through the residual stump. A notchplasty followed by femoral and tibial tunnels is created in a standard fashion. An Endobutton, soaked in a bacitracin solution, is then loaded with the sutures that were previously passed through the residual ACL stump and then through the femoral tunnel and cinched down to bone. The 4 suture ends that are coming from the Endobutton are then passed through the BEAR implant with the use of a Keith needle and shuttled through the tibial tunnel. The BEAR implant is hydrated with 15 cc of the patient's blood and is shuttled through the anteromedial portal with the knee in full extension. The 4 tibial sutures passed through the graft and tibial tunnel are passed, and tensioned to the proximal tibial with a second Endobutton. Standard closure and dressings are applied. Results: This new surgical implant and technique have shown noninferiority to ACL autograft reconstruction with respect to the International Knee Documentation Committee and anteroposterior laxity, with improved hamstring strength and decreased incidence of contralateral ACL tears at 2 years postoperative. Discussion/Conclusion: While initial data remain promising, future long-term designed studies are needed to determine the clinical efficacy of the BEAR technique, particularly comparing itself with bone-patellar tendon-bone autograft ACL reconstruction. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Comparison of Clinical Outcomes Between Modern Augmented ACL Repair and Autograft ACL Reconstruction: A Systematic Review and Meta-analysis of Studies With Minimum 2-Year Follow-up.

Anterior cruciate ligament (ACL) reconstruction has been the gold standard for primary ACL rupture since the 1990s. In the past decade, ACL repair has received renewed attention and increased research. To compare the clinical outcomes of modern augmented ACL repair versus autograft reconstruction for ACL ruptures. Systematic review; Level of evidence, 3. A search of the PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Library databases was conducted for prospective or retrospective comparative studies published between January 1, 2010, and January 3, 2023, with a minimum 2-year follow-up. Two independent reviewers performed data extraction and methodological quality assessment. Sensitivity analysis was performed to maintain the stability of results. Nine studies were included (minimum follow-up period, 24-60 months). The total sample size was 833 patients (augmented repair group: 358 patients; autograft ACL reconstruction group: 475 patients). There were 4 randomized controlled trials (level 1), 1 prospective comparative study (level 2), 2 retrospective comparative studies (level 3), and 2 case-control studies (level 3). The augmented ACL repair group attained significantly higher Lysholm score (weighted mean difference [WMD] = 1.57; 95% confidence interval [CI], 0.14-3.01; P = .03) and hamstring strength (WMD = 36.69; 95% CI, 29.07-44.31; P < .01) but had higher rates of hardware removal (odds ratio [OR] = 6.30; 95% CI, 2.44-16.23; P = .0001), reoperation (OR = 1.87; 95% CI, 1.33-2.62; P = .0003), and failure (OR = 1.58; 95% CI, 1.03-2.43; P = .0003) compared with the autograft ACL reconstruction group. No significant differences were observed between the repair and reconstruction groups regarding postoperative International Knee Documentation Committee scores, Tegner scores, knee laxity, satisfaction, ACL revisions, complications, and reoperation rather than revision. Augmented ACL repair was associated with higher rates of reoperation, hardware removal, and failure compared with autograft ACL reconstruction in studies with minimum 2-year follow-up data. However, augmented ACL repair had higher Lysholm scores and hamstring strength versus autograft ACL reconstruction.