Editorial Commentary: Anterior Cruciate Ligament Repair Revisited … Do We Need A Paradigm Shift?

Clinical Results of Primary Repair Versus Reconstruction of the Anterior Cruciate Ligament: A Systematic Review and Meta-analysis of Contemporary Trials

Background

Primary anterior cruciate ligament (ACL) repair has gained renewed interest in select centers for patients with proximal or midsubstance ACL tears. Therefore, it is important to reassess contemporary clinical outcomes of ACL repair to determine whether a clinical benefit exists over the gold standard of ACL reconstruction (ACLR).

Purpose

To (1) perform a meta-analysis of comparative trials to determine whether differences in clinical outcomes and adverse events exist between ACL repair versus ACLR and (2) synthesize the midterm outcomes of available trials.

Study Design

Systematic review; Level of evidence, 3.

Methods

The PubMed, OVID/Medline, and Cochrane databases were queried in August 2023 for prospective and retrospective clinical trials comparing ACL repair and ACLR. Data pertaining to tear location, surgical technique, adverse events, and clinical outcome measures were recorded. DerSimonian-Laird random-effects models were constructed to quantitatively evaluate the association between ACL repair/ACLR, adverse events, and clinical outcomes. A subanalysis of minimum 5-year outcomes was performed.

Results

Twelve studies (893 patients; 464 ACLR and 429 ACL repair) were included. Random-effects models demonstrated a higher relative risk (RR) of recurrent instability/clinical failure (RR = 1.64; 95% confidence interval [CI], 1.04-2.57; P = .032), revision ACLR (RR = 1.63; 95% CI, 1.03-2.59; P = .039), and hardware removal (RR = 4.94; 95% CI, 2.10-11.61; P = .0003) in patients who underwent primary ACL repair versus ACLR. The RR of reoperations and complications (knee-related) were not significantly different between groups. No significant differences were observed when comparing patient-reported outcome scores. In studies with minimum 5-year outcomes, no significant differences in adverse events or Lysholm scores were observed.

Conclusion

In contemporary comparative trials of ACL repair versus ACLR, the RR of clinical failure, revision surgery due to ACL rerupture, and hardware removal was greater for primary ACL repair compared with ACLR. There were no observed differences in patient-reported outcome scores, reoperations, or knee-related complications between approaches. In the limited literature reporting on minimum 5-year outcomes, significant differences in adverse events or the International Knee Documentation Committee score were not observed.

Primary Repair versus Reconstruction in Patients with Bilateral Anterior Cruciate Ligament Injuries: What Do Patients Prefer?

Purpose. The purpose is to evaluate knee preference and functional outcomes of patients with primary anterior cruciate ligament (ACL) repair in one knee and ACL reconstruction in the contralateral side. Methods. All patients who underwent both procedures were retrospectively reviewed at minimum two-year follow-up. Patients were asked to complete questionnaires regarding their operated knees’ preferences during rehabilitation, daily activities, sports activities, and overall function. Furthermore, the Subjective International Knee Documentation Committee, Forgotten Joint Score-12, and Anterior Cruciate Ligament-Return to Sport after Injury were completed. Results. Twenty-one patients were included. All patients underwent ACL reconstruction first, which was displayed at younger age at surgery (24 vs. 33 years, $p=0.010$ ) and longer follow-up (10.2 vs. 2.3 years, $p<0.001$ ), respectively. Thirty-three percent preferred the repaired knee, 11% the reconstructed knee, and 56% had no preference; however, 78% indicated that their repaired knee was less painful during rehabilitation and 83% reported earlier range of motion (ROM) return following repair, which was similar for both knees in 17%. Eighty-three percent of patients indicated better function and progression during rehabilitation with their repaired knee and 11% with their reconstructed knees. No statistical differences were found in patient-reported outcomes between both procedures (all $p>0.4$ ). Objective laxity assessment showed mean side-to-side difference of 0.6 mm between both sides in favor of the reconstructed knee. Conclusion. This study showed that ACL repair and ACL reconstruction lead to similar functional outcomes. However, patients undergoing both procedures may have less pain, earlier ROM return, and faster rehabilitation progression following primary repair.

Large variation in indications, preferred surgical technique and rehabilitation protocol for primary anterior cruciate ligament repair: a survey among ESSKA members

PURPOSE

To assess current surgical preferences and practice patterns regarding primary anterior cruciate ligament (ACL) repair among European Society for Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA) members.

METHODS

A web-based survey was designed, including questions regarding indications for primary repair, outcomes of primary repair, and rehabilitation protocols. An invitation for study participation was sent by email to all ESSKA e-mail contacts. Descriptive statistics were performed.

RESULTS

A total of 169 surgeons responded to the survey (7% response rate of active members). Lack of supporting scientific evidence is the main reason for not using repair as a surgical treatment (63%). Most important indications were proximal avulsion tears (84%), younger age (49%), and older age (34%). Among those currently utilizing repair as a treatment option, transosseous tunnel fixation repair (34%) and repair with internal brace using transosseous tunnel fixation (32%) were the most preferred techniques. Eleven percent indicated dynamic intraligamentary stabilization as their preferred technique. A similar rate of progression for rehabilitation for repair and reconstruction techniques was noted among respondents.

CONCLUSION

This practice survey shows that the majority of surgeons indicated the main reason for not incorporating primary repair in their current practices was a lack of supporting scientific evidence. Among those holding favourable attitudes and beliefs, most surgeons indicated patients with proximal tears, younger-aged, and older-aged patients might be eligible for repair. Prospective studies with higher levels of evidence are warranted to establish guidelines for repair, including indications, optimal surgical technique, and rehabilitation protocols.

LEVEL OF EVIDENCE

V (expert opinion).

AANA20: The 2020 Annual Meeting of the Arthroscopy Association of North America

Arthroscopy, Arthroscopy Techniques, and Arthroscopy, Sports Medicine, and Rehabilitation will be in attendance in force at the 2020 Annual Meeting of the Arthroscopy Association of North America (AANA20). Program highlights and innovations include surgery simulcasts, "Great Debates," award-winning papers, Feature Lectures, and sessions glimpsing what is On the Horizon-and perhaps over and beyond.