ACL Repair: A Game Changer or Will History Repeat Itself? A Critical Appraisal

Abstract

Until the past decade the common thought was that the anterior cruciate ligament (ACL) was not able to heal and restore knee stability. In this manuscript a brief review of studies of the developers and the early adaptors of four different modern ACL repair techniques are presented. The present status and considerations for the future of ACL repair and its research are shared. After promising short- to midterm ACL healing results by the developers, the results of the early adaptors show more variety in terms of rerupture and reintervention for other reasons. Risk factors for failure are a young age, high preinjury sports activity level, midsubstance ruptures and impaired integrity of the ACL bundles and the synovial sheath. There is a call for more clinical data and randomized clinical trials. Conclusion: an important finding of the past decade is that the ACL is able to heal and subsequently restabilize the knee. Patient selection is emphasized: the ideal patient is a non-high athlete older than 25 and has an acute proximal one bundle ACL rupture. Further research will have to show if ACL repair could be a game changer or if history will repeat itself.

Remnants-preserving ACL reconstruction using direct tendinous graft fixation: a new rat model

“…MRI and histology thus permitted in the present model to objectivate the absence of spontaneous healing 12 weeks after ACL transection without associated reconstruction. Some authors allocated the absence of spontaneous ACL healing to the gap formed between the ACL ends and subsequent interposition of synovial fluid, which impair the possibility of a guided regeneration process [5]. Indeed, healing of ACL remnants has been previously observed on histology 12 weeks after surgery in a goat model of mid-substance transection followed by locking suture, alone or combined with small intestine submucosa [56].…”

“…Evidence is still lacking in people regarding the superiority of ACL reconstructive surgery over conservative management on post-traumatic OA [2,61]. Some studies even suggested a worse OA long-term prognosis for operated ACL-deficient knees compared to knees treated conservatively [5]. Experimental studies in animals demonstrated that ACL reconstruction did not protect cartilages from degenerative changes [62].…”

“…Reconstructive surgery, which is usually performed using a tendinous autograft after entire resection of the ACL remnants [3], has become the advocated treatment of ACL injuries in young active people [4]. Still, morbidity and functional outcomes associated with this technique remain limiting factors, with autograft re-ruptures still occurring in up to 28% in highrisk populations, higher risk for developing moderate to severe osteoarthritis compared to non-surgically treated knees, bone tunnel widening, and persisting knee instability [5][6][7][8]. With the increasing interest for regenerative medicine, new emerging strategies focus now on sparing instead of excising the ACL remnants, to promote biological healing, through primary repair combined with augmentation using internal bracing, suture anchors, and synthetic devices, or through remnants' preservation and/or tensioning, combined with reconstruction using tendon grafts [9].…”

Injuries of Anterior Cruciate Ligament: A Review

“…24 Biologically augmented ACL repair is an upcoming approach to overcome this osteoarthritis and as well give a similar biomechanical outcome. 25,26…”

Anterior Cruciate Ligament (ACL) Injuries: Modern Strategy of Surgical Treatment (Review)

“…Кожна методика потребує ретельного підходу до вибору "випадок -пацієнт", однак результатів досліджень недостатньо, щоб розглядати ці способи в контексті стандартизованого підходу. Найбільш вагомими є дослідження S. Kohl, D. Evangelopoulos (2013) та H. Christiaan, W. Heusdens (2021) щодо застосування методики DIS як способу відновле ння ПСЗ [40,41]. Ця фіксація передбачає ушивання ушкодженої ділянки ПСЗ полідіоксаноновим шовним матеріалом та стабілізацію колінного суглоба швом, який проходить поряд із ПСЗ та фіксується на великогомілковій кістці за допомогою пружинно-гвинтової системи.…”