Proximal Anterior Cruciate Ligament Tears Research Articles

Bone bruise distribution predicts anterior cruciate ligament tear location in non-contact injuries.

It is unclear whether different injury mechanisms lead to divergent anterior cruciate ligament (ACL) tear locations. This study aims to analyse the relationship between bone bruise (BB) distribution or depth and ACL tear location. A retrospective analysis of 446 consecutive patients with acute non-contact ACL injury was performed. Only patients with complete ACL tears verified during subsequent arthroscopy were included. Magnetic resonance imaging (MRI) was used to classify BB location, BB depth, ACL tear location and concomitant injuries (medial/lateral meniscus and medial/lateral collateral ligament). Demographic characteristics included age, gender, body mass index (BMI), type of sport and time between injury and MRI. Multiple linear regression analysis was used to identify independent predictors of ACL tear location. One hundred and fifty-eight skeletally mature patients met the inclusion criteria. The presence of BB in the lateral tibial plateau was associated with a more distal ACL tear location (β = -0.27, p < 0.001). Less BB depth in the lateral femoral condyle showed a tendency towards more proximal ACL tears (β = -0.14; p = 0.054). Older age predicted a more proximal ACL tear location (β = 0.31, p < 0.001). No significant relationship was found between ACL tear location and gender, BMI, type of sport, concomitant injuries and time between injury and MRI. ACL tear location after an acute non-contact injury is associated with distinct patterns of BB distribution, particularly involving the lateral compartment, indicating that different injury mechanisms may lead to different ACL tear locations. Level III.

Two-Year Functional Outcomes of Nonsurgical Treatment in Concomitant Anterior Cruciate Ligament and Medial Collateral Ligament Injuries: A Case-Control Study.

The anterior cruciate ligament (ACL) is a common knee injury in high-intensity sports, which can cause early career loss in young athletes. Concomitant damage to other knee stabilizers may occur, such as the medial collateral ligament (MCL). Recent studies have shown that knee stability can increase without surgical intervention in patients with ACL and MCL injuries. Regarding the importance of functional tests in return to exercise prediction, this study aims to measure nonsurgical approach's long-term outcome for concomitant ACL and MCL injuries with a focus on functional tests. This is a case-control study with a 2-year follow-up. The case group consisted of patients who had provided written consent and completed their 2-year follow-up, and the control group was made up of healthy people who did not have any knee medical conditions and were matched by age, gender, and activity level. Physical examinations, Tegner and International Knee Documentation Committee questionnaires, and knee magnetic resonance imaging were conducted, and functional performance tests were performed after a 10-minute warm-up. Lody's index (the ratio of injured-to-uninjured knee results) was calculated. The data were analyzed using independent t-test, one-way analysis of variance, chi-squared test, and Fisher's exact test. The study involved 11 patients in each concomitant ACL and MCL injury cases and healthy control groups with a mean age of 32.4 and 28 years, respectively. None of the patients reported knee instability symptoms in the 2-year follow-up. More than half of the patients continued their sports field without reinjury, with no significant difference in activity levels between case and control groups. The 6-meter hop test and single-leg hop test showed no significant difference between case and control groups (p-value: 0.326, 0.859), and no significant difference was observed in the three Carioca, cocontraction, and Shuttle tests in the 2-year follow-up. Functional tests in ACL and MCL injuries revealed normal outcomes, implying a nonsurgical approach for patients with proximal ACL tears, better knee stability, and no significant differences between the injured and control groups.

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.

Anterior Cruciate Ligament Repair Using a Re-tensionable All-Suture Construct

Anterior cruciate ligament (ACL) tears are among the most common injuries to the knee. With recent improvements in imaging that allow for more precise identification of ACL tear patterns, improved techniques for repair, and advancements in biological augmentation, there has been a re-emerging interest in primary ACL repair, especially for acute proximal ACL tears. This article aims to describe a surgical technique for primary ACL repair using a re-tensionable all-suture–based construct.

Favorable Patient-Reported, Clinical, and Functional Outcomes 2 Years After ACL Repair and InternalBrace Augmentation Compared With ACL Reconstruction and Healthy Controls

Background: Recently, interest in anterior cruciate ligament (ACL) preservation and repair after proximal ACL tears has been resurrected. Although good clinical outcomes have been reported in the literature with adequate patient selection, to date detailed scientific evidence for the functional benefit of primary ACL repair with ligament augmentation is scarce. Purpose: To compare patient-reported, clinical, and functional outcomes in patients 2 years after ACL repair and InternalBrace augmentation (ACL-IB) with age- and sex-matched patients 2 years after ACL reconstruction (ACL-R) and with matched healthy controls. Study Design: Cohort study; Level of evidence, 3. Methods: In total, 29 patients 2 years after ACL-IB, 27 sex- and age- matched patients 2 years after ACL-R (hamstring autografts), and 29 matched healthy controls were included. Patient-reported outcomes were assessed using the International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, EQ-5D-5L, Tegner Activity Scale, and Anterior Cruciate Ligament Return to Sports after Injury scale. Surgery time was recorded. For clinical outcomes, range of motion and thigh and shank circumference were measured, and passive anterior translation was determined using the Rolimeter. Isokinetic muscle strength was measured using a Biodex dynamometer. The limb symmetry index (operated/contralateral or nondominant/dominant × 100), side-to-side differences (operated – contralateral, nondominant – dominant), and hamstring-quadriceps ratios were calculated for functional parameters. Failure and reoperation rates were not compared. Results: Two years after surgery, patients treated with ACL-IB showed good to excellent patient-reported outcomes comparable with those of patients after ACL-R. Surgery time, including concomitant surgeries, was significantly shorter in the ACL-IB group (mean, 81 minutes) compared with the ACL-R group (mean, 97 minutes) (P = .024). Isokinetic muscle strength was comparable between patient groups without significant differences in extensor and flexor strength or in hamstring-quadriceps ratios. Conclusion: These results suggest that ACL-IB achieves comparable patient-reported, clinical, and functional outcomes with ACL-R at 2 years postoperatively and, after careful patient selection, should be considered as a valuable early treatment alternative for proximal ACL tears. Registration: NCT04429165 (ClinicalTrials.gov identifier).

Surgical Treatment of an Unusual Ski Injury: Combined Tibial Fracture With Anterior Cruciate Ligament Avulsion and Segond Lesion

Background: Alpine skiing is considered to be a high-risk sport due to frequent knee injuries and lower limb fractures. The most common lower limb fracture is tibial shaft fracture, while the most common ligament injuries include anterior cruciate ligament (ACL) or medial collateral ligament tears. An injury rarely described in the literature is the association of a bony leg fracture with an ACL injury and Segond fracture. Indications: While the tibial fracture can be managed with intermedullary nailing and proximal ACL tears can be managed with primary repair, the combination of treatments including fixation of the Segond fracture is uncommon. Technique Description: We report combination treatment with nailing for the tibial fracture, primary repair for the ACL avulsion, and primary fixation of Segond fracture. Results: Simultaneous reduction and fixation of the fracture and stabilization of the knee with ACL and anterolateral ligament repair in a single stage resulted in an excellent outcome with complete healing of tibial fracture, ACL repair, and Segond fixation at final follow-up. Discussion/Conclusion: Even if combined leg fracture associated with ipsilateral ACL tear and Segond fracture is a very rare injury, the described technique based on 1-stage fixation of the 3 injuries is a viable option. This surgical technique can be considered a reparative treatment, with the goal of preserving the joint. 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.

Anatomic Arthroscopic Primary Repair of Proximal Anterior Cruciate Ligament Tears

Within the last decade, various highly diverse anterior cruciate ligament (ACL) preservation techniques have been proposed, as contemporary selective arthroscopic ACL preservation experienced a resurgence. Among surgical techniques, there are a variety of suturing, fixation, and augmentation methods, whereas a common thread, considering essential anatomic and biomechanical properties, is missing. This technique aims to anatomically reapproximate both the anteromedial (AM) and posterolateral (PL) bundles to their respective femoral footprints. Additionally, a PL compression stitch is performed to increase the ligament-bone contact area and recreate the anatomic vectors of the native bundles, therefore, creating a more anatomic and biomechanical construct. This technique is a minimally invasive procedure, with no graft harvesting nor tunnel drilling, which leads to decreased pain levels, earlier return of full range motion (ROM), and faster rehabilitation, while failure rates seem to be comparable to that of ACL reconstruction. We present an updated surgical technique of anatomic arthroscopic primary repair with suture anchor fixation for patients with proximal ACL tears.

Augmenting ACL Repair With Suture Tape Improves Knee Laxity: A Biomechanical Study.

Anterior cruciate ligament (ACL) repair is an alternative to reconstruction; however, suture tape support may be necessary to achieve adequate outcomes. To investigate the influence of suture tape augmentation (STA) of proximal ACL repair on knee kinematics and to evaluate the effect of the 2 flexion angles of suture tape fixation. Controlled laboratory study. Fourteen cadaveric knees were tested using a 6 degrees of freedom robotic testing system under anterior tibial (AT) load, simulated pivot-shift (PS) load, and internal rotation (IR) and external rotation loads. Kinematics and in situ tissue forces were evaluated. Knee states tested were (1) ACL intact, (2) ACL cut, (3) ACL repair with suture only, (4) ACL repair with STA fixed at 0° of knee flexion, and (5) ACL repair with STA fixed at 20° of knee flexion. ACL repair alone did not restore the intact ACL AT translation at 0°, 15°, 30°, or 60° of flexion. Adding suture tape to the repair significantly decreased AT translation at 0°, 15°, and 30° of knee flexion but not to the level of the intact ACL. With PS and IR loadings, only ACL repair with STA fixed at 20° of flexion was not significantly different from the intact state at all knee flexion angles. ACL suture repair had significantly lower in situ forces than the intact ACL with AT, PS, and IR loadings. With AT, PS, and IR loadings, adding suture tape significantly increased the in situ force in the repaired ACL at all knee flexion angles to become closer to that of the intact ACL state. For complete proximal ACL tears, suture repair alone did not restore normal knee laxity or normal ACL in situ force. However, adding suture tape to augment the repair resulted in knee laxity closer to that of the intact ACL. STA with fixation at 20° of knee flexion was superior to fixation with the knee in full extension. The study findings suggest that ACL repair with STA fixed at 20° could be considered in the treatment of femoral sided ACL tears in the appropriate patient population.

Age and Bone Bruise Patterns Predict Tear Location in the Anterior Cruciate Ligament

To assess the influence of demographic risk factors, anatomic risk factors, and injury mechanisms on anterior cruciate ligament (ACL) tear patterns. All patients undergoing knee magnetic resonance imaging at our institution for acute ACL tears (within 1 month of injury) in 2019 were retrospectively analyzed. Patients with partial ACL tears and full-thickness posterior cruciate ligament injuries were excluded. On sagittal magnetic resonance images, the proximal and distal remnant lengths were measured, and the tear location was calculated as the distal remnant length divided by the total remnant length. Previously reported demographic and anatomic risk factors associated with ACL injury were then reviewed, including the notch width index, notch angle, intercondylar notch stenosis, alpha angle, posterior tibial slope, meniscal slope, and lateral femoral condyle index. In addition, the presence and severity of bone bruises were recorded. Finally, risk factors associated with ACL tear location were further analyzed using multivariate logistic regression. A total of 254 patients (44% male patients; mean age, 34 years; age range, 9-74 years) were included, of whom 60 (24%) had a proximal ACL tear (tear at the proximal quarter). Multivariate enter logistic regression analysis showed that older age (P= .008) was predictive of a more proximal tear location whereas open physes (P= .025), bone bruises in both compartments (P= .005), and posterolateral corner injury (P= .017) decreased the likelihood of a proximal tear (R 2= 0.121, P < .001). No anatomic risk factors were identified to play a role in tear location. Although most patients have midsubstance tears, proximal ACL tears were more commonly found in older patients. Bone contusions involving the medial compartment are associated with midsubstance tears; these findings may indicate that different injury mechanisms play a role in the location at which the ACL tears. Level III, prognostic, retrospective cohort study.

Primary Repair for Treating Acute Proximal Anterior Cruciate Ligament Tears: A Histological Analysis and Prospective Clinical Trial.

Reconstruction surgery for acute proximal anterior cruciate ligament (ACL) tears remains controversial. Recently, ACL primary repair has received increasing attention in ACL treatment. This study aimed to explore the histological characteristics of ACL healing in primary repair and compare its therapeutic and prognostic results with the reconstruction of acute proximal ACL tears. Histological experiments using rabbits and a prospective clinical trial were conducted. We established a rabbit model of ACL primary repair, and histological changes were observed using haematoxylin and eosin (HE) and toluidine blue staining. We performed immunohistochemical analysis of CD34 and S-100 and measured the expression of collagen I and II using qRT-PCR, Western blotting, and immunohistochemistry. The prospective clinical trial involved performing ACL primary repair and reconstruction in patients with acute proximal ACL tears to detect proprioception and evaluate the function of joints. We discovered that primary repair promoted cell proliferation in the tendon-bone transition and ligament portions, reduced osteoarthritis-like pathological changes, and maintained blood vessels and proprioceptors within the ACL. In the clinical trial, primary repair achieved similar therapeutic outcomes, including recovery of knee function and proprioception, in the follow-up period as ACL reconstruction. However, the primary repair had a significantly shorter operative time and lower cost than reconstruction. Therefore, doctors should consider the benefit of primary repair in treating acute proximal ACL tears.

A Prospective Observational Study on Short-Term Functional Outcome of Arthroscopic Anterior Cruciate Ligament Repair of Proximal Tears Using Knotless Single Suture Anchor Technique.

To assess the clinical outcomes in patients with anterior cruciate ligament (ACL) proximal tears undergoing arthroscopic primary repair with knotless single suture anchor technique. The first twenty-two consecutive patients with proximal ACL tears (Sherman types I and II and high-grade partial tears) treated with arthroscopic primary repair with single suture anchor technique were evaluated until 6months post-operatively. Patients were evaluated with validated functional outcome measures (IKDC and Lysholm scores) and clinical tests for ACL stability. At 6-month follow-up, 91% of patients (n = 20) achieved excellent outcome measures for IKDC and Lysholm scores and had complete stability of the ACL to clinical testing. Two patients with poor outcomes at six weeks; one with subjective instability and the other underwent revision surgery represented a failure rate of 9%. The median Lysholm score was 96 (IQ range, 96-100) and median IKDC subjective score was 87.40 (IQ range, 78.20-88.50) at 6-month follow-up. The improvement in Lysholm and IKDC scores over a period of six months post-operatively was statistically significant when compared to preoperative scores (p ≪ 0.0001). Maximum improvement in clinical outcomes is achieved in the first 6weeks post-surgery with a slower increase thereafter, a time interval which may be considered as a figurative yield point for future work in this field. Arthroscopic ACL primary repair with knotless single suture anchor technique provides excellent short-term clinical outcomes in a carefully selected subset of patients with proximal ACL tears. More powered and longer duration studies are needed to understand longer term outcomes. Level IV, therapeutic case series.

Is ACL Repair Really Back? A Review of Modern Techniques

Anterior cruciate ligament (ACL) repair has been suggested to have several potential advantages over ACL reconstruction (ACLR) including preservation of both the native anatomy and the proprioceptive function of the knee. The initial open surgical techniques of ACL repair fell out of favor due to the limited success and unpredictability of the results. There has been a renewed interest in ACL repair given its biomechanical advantages, the advent of new arthroscopic surgical techniques, modern repair technology (implants and biological adjuncts), and perhaps a better understanding of which tear patterns may be more amenable to successful repair. More recently, ACL repair has been shown to be most successful in patients with proximal ACL tears and good tissue quality, as well as with the ability to biologically augment the repair. Midterm follow-up of these patients have promising outcomes in regards to patient satisfaction, stability, and return to work or sport. Broadly, the different ACL repair techniques include internal augmentation, enhancement of the biologic environment, and the use of secure femoral-sided footprint fixation. This article aims to summarize these studies and review the different techniques for ACL repair that have been described in the literature.

Arthroscopic Primary Repair of Proximal Anterior Cruciate Ligament Tears With Suture Augmentation

Background: Historically, the midterm outcomes of open anterior cruciate ligament (ACL) repair were rather disappointing, and ACL reconstruction subsequently became the surgical standard for ACL injuries. Recent studies, however, have shown that there might be a role for arthroscopic primary repair in appropriately selected patients with proximal ACL tears. Indications: Due to more prominent blood supply in the proximal ligament region, ACL repair should only be performed in patients with proximal tears and good-to-excellent tissue quality. Although all patients are potential candidates, this procedure is preferably performed acutely and in adult patients. Technique Description: First, it is identified whether a proximal tear with good tissue quality is present. Then, both ACL bundles are sutured individually from distal to proximal using a Bunnell-type pattern and a self-retrieving suture passer. The posterolateral bundle is then reattached first in anatomical fashion, using a 4.75-mm vented biocomposite suture anchor. Next, the suture anchor of the anteromedial bundle is preloaded with an internal suture tape augmentation. After anchor deployment, the suture tape augmentation is channeled through a small 2.5-mm tibial tunnel in the anterior third of the tibial ACL footprint. Finally, the suture augmentation is tensioned near full extension and fixed to the tibia’s anteromedial cortex using single suture anchor fixation. Results: Recently, we have published a series of the first 113 consecutive repair patients with minimum 2-year follow-up, of which 60 received additional suture augmentation. In this cohort, the overall failure rate was 13%, which was similar to 3 other studies on modern-day ACL repair (range: 5%-15%). Subgroup analysis showed that the failure rate was much higher in patients ≤21 years (38%) but low in patients &gt;21 years (0%). Finally, it has been shown that there is an earlier return of knee motion, complications are rare, and there is less joint awareness after ACL repair as compared with ACL reconstruction. Conclusion: Selective, modern-day, arthroscopic primary ACL repair with suture augmentation seems to be a good alternative to ACL reconstruction in carefully selected patients, which include patients with proximal tears and good tissue quality and aged ≥22 years.

Repair versus reconstruction for proximal anterior cruciate ligament tears: a study protocol for a prospective multicenter randomized controlled trial

BackgroundFor active patients with a tear of the anterior cruciate ligament (ACL) who would like to return to active level of sports, the current surgical gold standard is reconstruction of the ACL. Recently, there has been renewed interest in repairing the ACL in selected patients with a proximally torn ligament. Repair of the ligament has (potential) advantages over reconstruction of the ligament such as decreased surgical morbidity, faster return of range of motion, and potentially decreased awareness of the knee. Studies comparing both treatments in a prospective randomized method are currently lacking.MethodsThis study is a multicenter prospective block randomized controlled trial. A total of 74 patients with acute proximal isolated ACL tears will be assigned in a 1:1 allocation ratio to either (I) ACL repair using cortical button fixation and additional suture augmentation or (II) ACL reconstruction using an all-inside autologous hamstring graft technique. The primary objective is to assess if ACL repair is non-inferior to ACL reconstruction regarding the subjective International Knee Documentation Committee (IKDC) score at two-years postoperatively. The secondary objectives are to assess if ACL repair is non-inferior with regards to (I) other patient-reported outcomes measures (i.e. Knee Injury and Osteoarthritis Outcome Score, Lysholm score, Forgotten Joint Score, patient satisfaction and pain), (II) objective outcome measures (i.e. failure of repair or graft defined as rerupture or symptomatic instability, reoperation, contralateral injury, and stability using the objective IKDC score and Rollimeter/KT-2000), (III) return to sports assessed by Tegner activity score and the ACL-Return to Sports Index at two-year follow-up, and (IV) long-term osteoarthritis at 10-year follow-up.DiscussionOver the last decade there has been a resurgence of interest in repair of proximally torn ACLs. Several cohort studies have shown encouraging short-term and mid-term results using these techniques, but prospective randomized studies are lacking. Therefore, this randomized controlled trial has been designed to assess whether ACL repair is at least equivalent to the current gold standard of ACL reconstruction in both subjective and objective outcome scores.Trial registrationRegistered at Netherlands Trial Register (NL9072) on 25th of November 2020.

Satisfactory patient-reported outcomes at 5 years following primary repair with suture tape augmentation for proximal anterior cruciate ligament tears

PurposeAn enhanced understanding of anterior cruciate ligament (ACL) healing and advancements in arthroscopic instrumentation has resulted in a renewed interest in ACL repair. Augmentation of a ligament repair with suture tape reinforces the ligament and acts as a secondary stabilizer. This study assesses the 5-year patient-reported outcomes of primary repair with suture tape augmentation for proximal ACL tears.MethodsThirty-seven consecutive patients undergoing ACL repair with suture tape augmentation for an acute proximal rupture were prospectively followed up for a minimum of 5 years. Patients with midsubstance and distal ruptures, poor ACL tissue quality, retracted ACL remnants and multiligament injuries were excluded. Patient-reported outcome measures were collated using the Knee Injury and Osteoarthritis Outcomes Score (KOOS), Visual Analogue Pain Scale (VAS-pain), Veterans RAND 12-Item Health Survey (VR-12) and the Marx Activity Scale. Patients with a re-rupture were identified.ResultsThree patients were lost to follow-up leaving 34 patients in the final analysis (91.9%). The mean KOOS at 5 years was 88.5 (SD 13.8) which improved significantly from 48.7 (SD 18.3) preoperatively (p < 0.01). The VAS score improved from 2.3 (SD 1.7) to 1.0 (SD 1.5) and the VR-12 score improved from 35.9 (SD 10.3) to 52.4 (SD 5.9) at 5 years (p < 0.01). However, the Marx activity scale decreased from 12.4 (SD 3.4) pre-injury to 7.3 (SD 5.2) at 5 years (p = 0.02). Six patients had a re-rupture (17.6%) and have since undergone a conventional ACL reconstruction for their revision surgery with no issues since then. These patients were found to be younger and have higher initial Marx activity scores than the rest of the cohort (p < 0.05).ConclusionPrimary repair with suture tape augmentation for proximal ACL tears demonstrates satisfactory outcomes in 28 patients (82.4%) at 5-year follow-up. Six patients sustained a re-rupture and have no ongoing problems following treatment with a conventional ACL reconstruction. These patients were significantly younger and had higher initial Marx activity scores.Level of evidenceLevel IV.

Primary Anterior Cruciate Ligament Repair Using Suture Tape Augmentation: A Case Series of 29 Patients With Minimum 2-Year Follow-Up

To evaluate clinical outcomes and patient-reported outcomes of patients who underwent primary anterior cruciate ligament (ACL) repair using suture tape augmentation. Patients with a proximal tear of the ACL who underwent primary ACL repair with a minimum 2-year follow-up were included. The exclusion criteria included multiligamentous knee injuries, midsubstance tears, tibial avulsion fractures, and distal tears. Demographic characteristics, injury pattern, concomitant injury pattern, and patient-reported outcome measures were recorded. Patients were evaluated at a minimum 2-year follow-up for clinical success, defined as stability not requiring revision ACL reconstruction, and for patient-reported outcome measurements. Failure was defined as the need for revision surgery. The mean follow-up period was 2.8 ± 0.9 years. Thirty-five patients met the inclusion criteria, with an average age of 32.2 ± 7.2 years, and 2-year follow-up was obtained for 29 of these patients. Revision surgery was required in 2 of the 29 patients (6.9%); successful treatment was achieved in the remaining 93.1%. The Single Assessment Numeric Evaluation score and Knee Injury and Osteoarthritis Outcome Score for the 27 successfully treated patients were recorded, with 70.4% having Single Assessment Numeric Evaluation scores of 80 or greater. This case series shows that primary surgical repair of proximal ACL tears using suture tape augmentation results in a low rate of revision surgery. Level IV, prospective case series.

An arthroscopic repair technique for proximal anterior cruciate tears in children to restore active function and avoid growth disturbances

PurposeThe aim of this study was to assess midterm clinical outcomes in Tanner 1–2 patients with proximal anterior cruciate ligament (ACL) tears following arthroscopic-surgical repair using an absorbable or an all-suture anchor.MethodsFourteen (9.2 ± 2.9 years-old) of 19 skeletally immature patients reached the 2 years of clinical follow-up. Physical examinations included the Lachman test, Pivot-shift test, One-leg Hop test, Pedi-IKDC as well as Lysholm and Tegner activity scores; knee stability was measured with a KT-1000 arthrometer. Overall re-rupture rates were also evaluated in all operated patients.ResultsAt 2 years post-surgery, the Lysholm score was 93.6 ± 4.3 points, and the Pedi-IKDC score was 95.7 ± 0.1. All patients returned to the same sport activity level as prior to ACL lesion within 8.5 ± 2.9 months, with one exception who reported a one-point reduction in their Tegner Activity score. No leg-length discrepancies or malalignments were observed. Four patients presented grade 1 Lachman scores, and of these, three presented grade 1 (glide) score at Pivot-shift; clinical stability tests were negative for all other patients. Anterior tibial shift showed a mean side-to-side difference of 2.2 mm (range 1–3 mm). The One-leg Hop test showed lower limb symmetry (99.9% ± 9.5) with the contralateral side. Overall, 4 out of 19 patients presented a re-rupture of the ACL with a median time between surgery and re-rupture of 3.9 years (range 1–7).ConclusionThis surgical technique efficiently repairs proximal ACL tears, leading to a restoration of knee stability and a quick return to an active lifestyle, avoiding growth plate disruption.Level of evidenceIV.

Role of Age on Success of Arthroscopic Primary Repair of Proximal Anterior Cruciate Ligament Tears

To assess failure rates and patient-reported outcomes measures following arthroscopic primary anterior cruciate ligament (ACL) repair of proximal tears in different age groups. Between 2008 and 2017, the first 113 consecutive patients treated with repair were retrospectively reviewed at minimum of 2 years. Patients were stratified into 3 age groups: ≤21, 22-35, and >35 years. Primary outcomes were ipsilateral reinjury or reoperation, and contralateral injury rates, and secondary outcomes consisted of Lysholm, modified Cincinnati, Single Assessment Numeric Evaluation, International Knee Documentation Committee subjective, pain, and satisfaction scores. Group differences were compared using χ2 tests and Mann-Whitney U tests. Follow-up was obtained in 113 patients (100%). Median age was 35 years (interquartile range [IQR] 23-43) and median follow-up was 2.2 years (IQR 2.0-2.8). Overall, ACL reinjury occurred in 13 patients (11.5%), reoperation in 7 patients (6.2%), complications in 2 patients (1.8%) and contralateral ACL injury in 4 patients (3.5%). Overall, median Lysholm was 95 (IQR 89-100) and International Knee Documentation Committee subjective 92 (IQR 84-99). Treatment failure was significantly greater in the youngest age group (37.0%) as compared with the middle and older groups (4.2% and 3.2%, both P < .005). No significant differences were seen in reoperation, complication, or contralateral injury rates between groups (all P > .2), nor in patient-reported outcomes measures between the groups (all P > .1). The failure rate of primary repair of proximal ACL tears is high in patients aged 21 or younger (37.0%), and this should be taken into account when discussing repair in this patient group. In patients older than 21, repair may be an excellent treatment with low failure (3.5%) and complication rates (1.2%) and good subjective scores. Level III, retrospective comparative therapeutic trial.

Distal remnant length can be measured reliably and predicts primary repair of proximal anterior cruciate ligament tears.

To assess the reliability and predictive value of quantifying anterior cruciate ligament (ACL) tear location on magnetic resonance imaging (MRI) and assess the predictive value of tear location on the eligibility for arthroscopic primary repair of proximal ACL tears. In this case-control study, all adult patients undergoing acute ACL surgery between 2008 and 2020 were retrospectively reviewed. All patients were treated with the treatment algorithm of undergoing primary repair when proximal tears with sufficient tissue quality were present intraoperatively, and otherwise underwent single-bundle ACL reconstruction. Sagittal MRI images were reviewed to measure proximal and distal remnant lengths along the anterior aspect of the torn ligament, and tear location was calculated as distal remnant divided by total remnant length. Interobserver and intraobserver reliability for remnant measurements were calculated. Then, receiver operating curve analysis (ROC) was performed to calculate the optimal cut-off for the possibility of primary repair with the different measurements. Two hundred and forty-eight patients were included, of which 151 underwent repair (61%). Inter- and intraobserver reliability ranged between 0.92 and 0.96 [95% confidence interval (CI) 0.55-0.98] and 0.91-0.97 (95% CI 0.78-0.98, respectively). All patients with a tear location of ≥ 80% on MRI could undergo repair, whereas all patients with tear location of < 60% required reconstruction. The positive predictive value of a proximal quarter tear (≥ 75%) on primary repair was 94%. Older age was correlated with more proximal tear location (p < 0.001), but there was no correlation between tear location and gender, BMI, or timing of surgery (all n.s). This study showed that tear location could reliably be quantified on MRI by assessing distal and proximal remnant lengths. Tear location in the proximal quarter of the ACL was found to have a positive predictive value for repairability of 94%. These findings may assist orthopaedic surgeons in evaluating which patients are eligible for primary ACL repair preoperatively. III.

The healing potential of an acutely repaired ACL: a sequential MRI study

BackgroundRecently, there has been renewed interest in primary anterior cruciate ligament (ACL) repair. The aim of this study is to report early clinical and radiological results of a consecutive series of acute ACL tears treated with arthroscopic primary ACL repair within 14 days from injury.Patients and methodsA consecutive series of patients with acute ACL tears were prospectively included in the study. Based on MRI appearance, ACL tears were classified into five types, and tissue quality was graded as good, fair, and poor. Patients with type I, II, and III tears and at least 50% of ACL tibial remnant intact with good tissue quality were ultimately included. Clinical outcomes were measured using the Tegner Lysholm Knee Scoring Scale (TLKSS), the Knee Injury and Osteoarthritis Outcome Score (KOOS), subjective and objective International Knee Documentation Committee (IKDC) scores, and KT-1000. Patients were also followed up with MRI evaluations at 1, 3, and 6 months postoperatively. ACL appearance was graded based on morphology (normal or abnormal) and signal intensity (isointense, intermediate, and hyperintense).ResultsThe mean TLKSS was 98.1, the mean subjective IKDC was 97.6, and the mean KOOS was 98.2. The objective IKDC score was A in eight of ten patients and B in two patients. KT-1000 measurements showed a maximum manual side-to-side difference of less than 2 mm in eight of ten patients, whereas two patients showed a difference of 3 mm. The morphology of the repaired ACL was normal (grade 1) at 1 month follow-up in ten of ten cases, and this appearance persisted at 3 and 6 months postoperatively. The signal intensity at 1 month postoperatively was graded as isointense (grade 1) in four of ten patients, intermediate (grade 2) in five of ten patients, and hyperintense (grade 3) in one of ten patients. At both 3 and 6 months postoperatively, the signal intensity was graded as isointense (grade 1) in nine of ten patients and intermediate (grade 2) in one of ten patients.ConclusionsArthroscopic primary ACL repair performed acutely in a carefully selected group of patients with proximal ACL tears and good tissue quality showed good early clinical and radiological results.Level of evidenceLevel 4.