Proximal Anterior Cruciate Ligament Ruptures Research Articles

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.

Combined Anterior Cruciate Ligament Repair and Anterolateral Ligament Internal Brace Augmentation: Minimum 2-Year Patient-Reported Outcome Measures.

Background:The anterolateral ligament (ALL) contributes to anterolateral rotational stability of the knee. Internal bracing of the anterior cruciate ligament (ACL) and ALL reinforces the ligaments and encourages natural healing by protecting both during the healing phase and supporting early mobilization.Purpose/Hypothesis:To assess the 2-year patient-reported outcomes of combined ACL repair and ALL internal brace augmentation. We hypothesized that significant improvements in outcomes would be seen.Study Design:Case series; Level of evidence, 4.Methods:A total of 43 consecutive patients with acute proximal ACL ruptures were prospectively evaluated for a minimum of 2 years. The mean age at the time of surgery was 25.7 years (range, 13-56 years). Indications for the combined ACL/ALL procedure were associated Segond fractures, grade 3 pivot shift, or high levels of sporting activity. Patients with chronic ruptures or with multiligament injuries were excluded. The Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, Veterans RAND 12-Item Health Survey (VR-12), and Marx activity scale were collected preoperatively and at 12 and 24 months postoperatively. Patients with any postoperative complications were identified at the time of this analysis.Results:The mean follow-up period was 44.8 months. Five patients were lost to follow-up, leaving 38 patients (88.4%) in the final analysis. The mean KOOS for Pain, Symptoms, Activities of Daily Living, Sport/Recreation, and Quality of Life improved from a respective 64.9, 58.6, 75.0, 33.7, and 28.9 preoperatively to 91.1, 81.8, 96.1, 82.8, and 74.3 at the 2-year follow-up (P < .0001). The mean WOMAC scores for pain, stiffness, and function improved from 77.5, 65.3, and 75.0 preoperatively to 94.6, 88.6, and 96.0 at the 2-year follow-up (P < .0001). The VAS pain score improved from 3.4 preoperatively to 0.7 at the 2-year follow-up, and the VR-12 physical score improved from 34.4 preoperatively to 52.7 at the 2-year follow-up (P < .0001 for both ). However, the Marx activity score decreased from 13.3 preinjury to 10.6 at the 2-year follow-up (P = .01). Two patients (5.3%) sustained a rerupture.Conclusion:Combined ACL repair and ALL internal brace augmentation demonstrated excellent outcomes in 94.7% of the study patients. Based on our experience with this cohort as well as our isolated ACL repair data, we suggest that high-risk patients with ACL ruptures have an additional ALL procedure to provide rotational stability.

Efficacy of Nonaugmented, Static Augmented, and Dynamic Augmented Suture Repair of the Ruptured Anterior Cruciate Ligament: A Systematic Review of the Literature

Background: Anterior cruciate ligament suture repair (ACLSR) was abandoned late last century in favor of anterior cruciate ligament (ACL) reconstruction (ACLR) because of overall disappointing results. However, in recent years there has been renewed and increasing interest in ACLSR for treatment of ACL ruptures. Several contemporary ACLSR techniques are being used, but any difference in effectiveness is unclear. Hypothesis: Contemporary nonaugmented (NA), static augmented (SA), and dynamic augmented (DA) ACLSR leads to (1) comparable outcomes overall and (2) comparable outcomes between proximal third, middle third, and combined ACL rupture locations (a) within and (b) between ACLSR technique categories. Study Design: Systematic review. Methods: An electronic search was performed in the MEDLINE and Embase databases for the period between January 1, 2010, and August 7, 2019. All articles describing clinical and patient-reported outcomes for ACLSR were identified and included, and outcomes for NA, SA, and DA ACLSR categories were compared. Results: A total of 31 articles and 2422 patients were included. The majority of articles (65%) and patients (89%) reported outcomes of DA ACLSR. Overall, there was high heterogeneity in study characteristics and level as well as quality of evidence (19 level 4; 7 level 3; 3 level 2; and 2 level 1). Most studies indicated excellent patient-reported outcomes. Overall, the variability in (and the maximum of) the reported failure rate was high within all ACLSR categories. The variability in (and the maximum of) the reported rate of all other complications was highest for DA ACLSR. Regarding ACL rupture location, the failure rate was highest in proximal ACL ruptures within the SA and DA ACLSR categories; rates of all other reported complications were highest in combined ACL ruptures within the DA ACLSR category. However, no studies in the NA category and only 1 study in the SA ACLSR category evaluated combined ACL ruptures. The majority of studies comparing ACLSR and ACLR found no differences in outcomes. Conclusion: The amount of high-quality evidence for contemporary ACLSR is poor. This makes it difficult to interpret differences among ACLSR categories and among ACL rupture locations and, though promising, to establish the role of ACLSR in the treatment of ACL ruptures. More high-quality large randomized clinical trials with longer follow-up comparing ACLSR and ACLR are needed.

Paediatric proximal ACL tears managed with direct ACL repair is safe, effective and has excellent short-term outcomes.

Anterior cruciate ligament (ACL) surgery in the paediatric population has long been a challenge. Non-operative treatment will result in persistent instability which can lead to chondral and meniscal injuries. The results of primary open ACL repair are poor. Concerns of growth plate disturbance with transphyseal techniques and issues with relatively small-diameter grafts in Tanner 1 and 2 patients, which are inadequate, have contributed to these challenges. With advancing instrumentation, there is renewed interest in ACL repair. The minimally invasive approach of arthroscopic primary ACL repair retains the native ligament. The objective and subjective outcomes at 2years are presented. Paediatric patients, less than 16years of age, presenting acutely with complete proximal ACL ruptures underwent direct arthroscopic ACL repair, reinforced by a temporary internal brace, which was subsequently removed after 3months. Patient-reported outcome measures including the Lysholm, Tegner and KOOS scores were collected at 6months, 1year and 2years post-operatively. Twenty patients (age 6-16) completed data at 2years post-operatively. There were no failures, no complications and no growth disturbance out to 2years. The 2-year postoperative outcomes; Lysholm 95 (90-100), Tegner 7 (6-10), KOOS-Child 96.5 (88.9-100) demonstrated statistically significant improvements following surgery (p < 0.001). Objective measurements with an accelerometer did not demonstrate any significant side-to-side difference. ACL repair for proximal ACL tears in the paediatric population demonstrates the potential for excellent outcomes at short-term follow-up. This presents an attractive alternative to ACL reconstruction when an adequate ACL remnant permits direct repair. Our results demonstrate that paediatric ACL repair is safe and effective.

Seventy percent long-term survival of the repaired ACL after dynamic intraligamentary stabilization.

Primary repair of the anterior cruciate ligament (ACL) is regaining popularity. Long-term results are lacking. The purpose of the current study was to determine the survival of the primarily repaired ACL after dynamic intraligamentary stabilization. Between 2011 and 2013, 57 patients with acute proximal ACL ruptures underwent DIS repair within 3weeks from injury and were available for final follow-up at least 5years postoperatively. Failure as an end point was defined as conversion to ACL reconstruction, failure to restore stability with persisting laxity side-to-side laxity of > 5mm or a late-traumatic re-rupture or loss of stability. Kaplan-Meier survival analysis was performed. Kaplan-Meier survival analysis demonstrated an overall survival of 70.0% (standard error SE 6.6%) at 74months follow-up. Patients performing competitive sports prior to injury demonstrated an inferior long-term ACL survival of 56.4% (SE 11.6%). Patients performing recreational sport activities demonstrated a survival rate of 79.2% (SE 7.7%). The one factor demonstrating a direct influence on failure after adjustment was a high-pre-injury level of physical (odds ratio 4.0 confidence interval 1.0-15.8, p = 0.04). The minimum 5years survival rate after primary ACL repair using this technique was 70%. This value dropped to 56% in highly active patients performing competitive sports. Patients not suffering failure of repair demonstrated adequate restoration of knee laxity and high satisfaction. This study not only underlines the potential of ACL repair, but also highlights the danger of the procedure if strict patient selection is not appreciated. Level IV.

Dynamic intraligamentary stabilization for ACL repair: a systematic review.

It was the aim to assess all published original research dealing with dynamic repair of the anterior cruciate ligament (ACL) and to provide a semi-quantitative analysis of clinical outcome reports. Both OVIS and MEDLINE databases were utilized for allocation of articles. All preclinical and clinical studies related to dynamic intraligamentary stabilization (DIS) were identified. Results were tabulated and semi-quantitative analysis performed. Twenty-three articles related to DIS were identified. The predominant level of evidence ranged between II and IV, with only one level I study. Reported failure rates ranged between 4% and 13.6%. Most clinical studies only reported revision rates without referring to failure of restoring stability. Highest success was achieved with proximal ACL ruptures. Both the level of physical activity and patient age have been found to influence the risk of failure. There is sufficient evidence to support that DIS repair may be an effective modality forthe treatment of acute proximal tears of the ACL. However, comparative studies are lacking. Upcoming studies should compare the technique to ACL reconstruction with failure as an endpoint. Comparison to rigid methods of proximal fixation is also necessary to justify the need for dynamic fixation. Overall, there is evidence to suggest the potential space for ACL repair in the decision tree for individualized treatment planning. The best outcome will be in the hands of the best patient selectors. IV.

Mittel- bis langfristige Ergebnisse nach vorderer Kreuzbandruptur und Versorgung in Healing-Response-Technik

Healing response (HR) is an all-arthroscopic technique for treatment of acute proximal anterior cruciate ligament (ACL) tears within 6 weeks after injury. By means of arthroscopically controlled microfracture holes in the native femoral attachment and perforations of the ACL itself the exit of stem cells and growth factors is induced and the ligament can heal into its native attachment zone. The purpose of the study was to document medium- to long-term results after 5 years or longer following the healing response (HR) procedure. The aim of our study was to show that HR is a treatment option for acute proximal ACL tears. Between 2004 and 2007 126 patients were treated in healing response technique in our hospital. Patients with a complete proximal ACL tear and operation within 6 weeks of initial injury were included in this study. Patients who had complex knee injuries with multidirectional instability, ACL rerupture, contralateral ACL reconstruction, contralateral ACL rupture or knee replacement and cartilage repair procedures (AMIC, MACT, OATS) were excluded. 43 (23 women/20 men; mean age at time of surgery 36.6 years ± 11.6; range: 16 to 66 years) of 89 eligible patients received clinical follow-up up to 8 years after surgery (mean: 6.3 years). Lysholm score, Tegner activity score, a modified IKDC-2000 knee examination form and an individually created questionnaire were used for evaluation. Furthermore, range of motion, muscle circumference of the lower limb and the anterior tibial translation were measured with a KT-1000 arthrometer™ (MEDmetric® Corporation, San Diego, USA). 15.1 % of all patients showed a primary insufficiency after HR. 24.6 % of the 126 patients required subsequent ACL reconstruction up to the time of data collection. The 43 patients who received clinical follow-up showed a mean Lysholm score of 92 ± 8.9 points. 72 % reached their original level of activity in the Tegner activity score. According to the IKDC evaluation system 90.7 % of all patients were grade A. 93 % did not show muscles atrophies of the lower limb. There were no limitations in range of motion. Mean side-to-side difference in the KT-1000 manual-maximum displacement test measurements was 1.3 mm ± 1.6 mm. 97.7 % patients had a normal or nearly normal knee function and 86 % rated the overall treatment as good to very good. Patients with good clinical results 6 to 12 weeks after HR show even in the medium- to long-term follow-up good clinical outcomes as well as objective stability. In selected cases HR is an alternative treatment option for acute, proximal ACL ruptures. When indicating an HR procedure, it should be taken into consideration that up to 15 % of all patients could have a primary insufficiency.

Clinical experience with PDS II augmentation for operative treatment of acute proximal ACL ruptures - 2-year follow-up

The results of prospective anterior cruciate ligament (ACL) refixation in 33 patients with high proximal rupture is reported at 20-28 months' follow-up: mean age was 31.1 +/- 12.5 years. The surgical technique was a specially developed refixation of the ACL using a multiple suture loop (modified Marshall technique) augmented with intra-articular PDS II (polydioxanon, resorbable, Ethicon, Hamburg, Germany) to avoid derangement of blood circulation and to guarantee early functional rehabilitation. All patients were operated on within 7.3 +/- 4.5 days after injury. According to the IKDC evaluation score, 22 patients showed excellent and 10 patients good subjective function. Twenty regained their pre-injury level of activity. Anterior stability was tested manually and by KT-1000 max (Medmetric, San Diego). Twenty-eight patients had a firm end-point, although there was a positive Lachman test in 16 patients. Maximal joint laxity as measured by KT-1000 showed a 1-2 mm, 3-5 mm, 6-10 mm and > 10 mm anterior drawer for 16, 14, 2 and 1 patients, respectively. Twenty-five of the evaluated knee joints had a negative pivot shift test. Three patients had a limited range of motion. The potential advantages of PDS II-augmented refixation of acute proximal ACL ruptures are anatomic reconstruction without destruction of other anatomic structures used as grafts, early functional rehabilitation and possibly better proprioception.

Acutely repaired proximal anterior cruciate ligament ruptures in sheep - by augmentation improved stability and reduction of cartilage damage.

The aim of this study was to evaluate the healing capacity of proximal anterior cruciate ligament (ACL) ruptures following primary repair with and without a bioresorbable augmentation. The ACL was transected at the femoral origin in the right knee joint of 24 sheep. The ACL was repaired in eight sheep (group B) without, and in eight sheep (group C) with a bioresorbable augmentation. Eight sheep without repair served as a control (group A). No immobilization was performed in any group. The sheep were sacrificed 13 weeks post-operatively. Macroscopically, all repaired ACLs were healed. The augmentation device was broken in all cases, but not completely degraded. In group A, none of the transected ACLs had healed. The anterior drawer under a load of 50 N was significantly lower in group C than in group A (p<0.01). No significant difference was seen between groups B and A. The distribution and extent of chondromalacia (CM) in the operated knees depended on the type of operative treatment (p<0.01). Groups A and B showed significantly more CM in the operated knee than in the non-operated knee (each p<0.05). Proximal ACL ruptures can heal in sheep after both non-augmented and augmented ACL repair with free-functional rehabilitation. However, augmented repair leads to significantly better stability of the knee joint compared to transected controls and better limits the development of degenerative changes.

Combined injury of the anterior cruciate ligament and the medial collateral ligament of the knee joint--results of two to six years follow-up of surgical treatment

A retrospective study of 148 combined acute knee injuries with anterior cruciate and medial collateral ligament injuries was performed. Follow-up included 115 patients, 95 of whom were personally examined two to six years postoperatively. Proximal anterior cruciate ligament ruptures were treated with reinsertion in 96 patients, in case of intraligamentous lesions (44 times), augmentation with the semitendinosus tendon was performed. Medial collateral ligament lesions were explored during the operation. Reconstruction of intraligamentous ruptures was performed with sutures (120 times). Distal lesions were refixed with Burri plate or staple. A modified Ellison procedure was routinely performed. Postoperative treatment was cast-free and included immediate physiotherapy using a functional brace. Between the two groups with anterior cruciate ligament reinsertion and augmentation, no significant differences were observed in subjective evaluation (Lysholm score 85 vs. 88), activity level (Tegner score 5.5 vs. 5.4) or anterior stability (KT 1000 at 89 N 6.6 vs. 6.1 mm displacement). A clear pivot shift sign was noted in two knees with reinsertion and in none of the augmented group. Medial stability was reestablished almost completely, independent of the site of lesion or the reconstruction technique (average valgus movement at 30 degrees flexion 0.7+ vs. 0.5+ on injured/contralateral side). We conclude that reinsertion of femoral anterior cruciate ligament ruptures will reestablish anterior stability in most cases, although semitendinosus augmentation appears to give slightly more reliable results. Medial stability is gained by the site-depending reconstruction techniques. Whether intraligamentous medial collateral ligament lesions can be left alone with only the anterior cruciate ligament being reconstructed, cannot be answered by this study.