The modern-day ACL surgeon's armamentarium should include multiple surgical approaches including primary repair, augmentation, and reconstruction: A letter to the Editor

Rilk, Sebastian; Saithna, Adnan; Ferretti, Andrea; Sonnery‐Cottet, Bertrand; Kösters, Clemens; Bottoni, Craig R.; Monaco, Edoardo; Cavaignac, Étienne; Brandl, Georg; Mackay, Gordon; Vermeijden, Harmen D.; Dallo, Ignacio; Pace, J. Lee; List, Jelle P. van der; Moggia, Jesús Rey; Chahla, Jorge; Batista, Jorge; Smith, Patrick A.; Frank, Rachel M.; Hoogeslag, Roy A.G.; Douoguih, Wiemi A.; DiFelice, Gregory S.

doi:10.1016/j.jisako.2023.03.434

Cited by 10 publications

(4 citation statements)

References 21 publications

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“…As already stated in Part 2 of this consensus process, repair also plays a role in acute proximal ACL ruptures [1]. We agree with Rilk et al that “ACL surgeon's armamentarium should include multiple surgical approaches including primary repair, augmentation, and reconstruction” [48]. However, this is a completely different method than the ACL reconstruction, which would have gone beyond the scope of this work.…”

Section: Discussionmentioning

confidence: 55%

Management after acute injury of the anterior cruciate ligament (ACL). Part 3: Recommendation on surgical treatment

Häner,

Stoffels,

Guenther

et al. 2024

Knee surg. sports traumatol. arthrosc.

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PurposeThe aim of this consensus project was to give recommendations regarding surgical treatment of the anterior cruciate ligament (ACL) injured patient.MethodsFor this consensus process, an expert, steering and rating group was formed. In an initial online meeting, the steering group, together with the expert group, formed various key topic complexes for which multiple questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement.ResultsDuring this consensus process, 30 topics regarding the surgical management and technique of ACL reconstruction were identified. The literature search for each key question resulted in 30 final statements. Of these 30 final statements, all achieved consensus.ConclusionsThis consensus process has shown that surgical treatment of ACL injury is a complex process. Various surgical factors influence patient outcomes. The proposed treatment algorithm can be used as a decision aid for the surgeon.Level of EvidenceLevel V.

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Section: Discussionmentioning

confidence: 55%

Management after acute injury of the anterior cruciate ligament (ACL). Part 3: Recommendation on surgical treatment

Häner,

Stoffels,

Guenther

et al. 2024

Knee surg. sports traumatol. arthrosc.

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“…In the literature commonly reported ACL refixation methods include the cinch loop (CL) techniques or modified Bunnell-type stitch configurations [10,11]. In contrast, bony fixation techniques such as knotless suture anchor and knotted cortical button fixation have recently been biomechanically evaluated for stability and are both used in daily clinical practice [10][11][12][13]. A recent biomechanical comparison study of three different retensioning methods using a porcine model by Ryu and colleagues found that the number and arrangement of stitches through the ACL has a significant effect on the pull-out force and stability [14].…”

Section: Discussionmentioning

confidence: 99%

“…In ACL reserving techniques, the (partially) ruptured ligament is sutured or reattached and thereby preserved. The benefits of arthroscopic ACL preserving techniques to restore normal knee function have been described and widely discussed in recent years [10][11][12]17]. Indications for these techniques, in particular cases with a femoral avulsion of the cruciate ligament, are described in the literature and should be considered by surgeons as a viable therapeutic option [10,12].…”

Section: Introductionmentioning

confidence: 99%

“…The benefits of arthroscopic ACL preserving techniques to restore normal knee function have been described and widely discussed in recent years [10][11][12]17]. Indications for these techniques, in particular cases with a femoral avulsion of the cruciate ligament, are described in the literature and should be considered by surgeons as a viable therapeutic option [10,12]. The prerequisite for these techniques appears to be a tear close to the proximal attachment of the cruciate ligament and good tissue quality of the ACL stump [10].…”

Section: Introductionmentioning

confidence: 99%

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Refixation of the anterior cruciate ligament: A biomechanical analysis of suture techniques in a porcine model

Lutter,

Hiller,

Sass

et al. 2024

J. exp. orthop.

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PurposeRefixation of acute anterior cruciate ligament (ACL) tears represents an increasingly popular treatment option. Systematic evaluations of various suture technique parameters are still pending. We therefore aimed to evaluate the mechanical pull‐out outcomes of various suture methods for optimization of ACL refixation.MethodsSixty fresh knees from mature domestic pigs were dissected and the femoral attachment of the ACL was peeled off. The 60 knees were divided in 10 groups and sutured as follows: (A) one suture (1, 2, 4 and 6 passes), (B) two sutures (2, 4 and 6 passes each; sutures knotted together as a loop) and (C) two sutures (2, 4 and 6 passes each, sutures knotted separately). The pull‐out test was conducted using a validated electrodynamic testing machine. First occurrence of failure, maximum pull‐out load and stiffness were measured. Suture failure was defined as pull‐out of the ACL.ResultsTwo‐point fixation, using two sutures, with at least two passes, showed the most favourable biomechanical stability. The maximum pull‐out load was significantly higher with two sutures (529.5 N) used compared to one (310.4 N), p < 0.001. No significant differences were found for maximum pull‐out loads between two‐point fixation versus one‐point fixation but stiffness was significantly higher with two‐point fixation (107.4 N/mm vs. 79.4 N/mm, p < 0.001). More passes resulted in higher maximum pull‐out loads.ConclusionThe results suggest using two independent sutures, refixed separately and at least two suture passes, is appropriate for ACL refixation. More suture passes provide additional strength but are technically challenging to achieve during surgery.Level of EvidenceLevel IV.

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Anterior cruciate ligament primary repair revision rates are increased in skeletally mature patients under the age of 21 compared to reconstruction, while adults (>21 years) show no significant difference: A systematic review and meta‐analysis

Rilk,

Goodhart,

van der List

et al. 2024

Knee surg. sports traumatol. arthrosc.

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PurposeTo evaluate the impact of age as a risk factor on the revision rates of anterior cruciate ligament (ACL) primary repair (ACLPR), dynamic intraligamentary stabilization (DIS) and bridge‐enhanced ACL restoration (BEAR) compared to ACL reconstruction (ACLR).MethodsA systematic literature search was performed for comparative studies comparing outcomes for ACLPR, DIS or BEAR to ACLR. A random‐effects meta‐analysis was performed to assess nondifferentiated and age‐differentiated (skeletally mature patients ≤21 and >21 years) ACL revision and reoperation risk, as well as results for subjective outcomes. Methodological study quality was assessed using the Risk of Bias Tool 2.0c and Methodological Index for Nonrandomized Studies tools.ResultsA total of 12 studies (n = 1277) were included. ACLR demonstrated a lower nonage‐stratified revision risk at 2 years versus ACLPR, DIS and BEAR, but a similar revision risk at 5 years when compared to DIS. However, an age‐stratified analysis demonstrated a significantly increased ACLPR revision risk as compared to ACLR in skeletally mature patients ≤21 years of age (risk ratios [RR], 6.33; 95% confidence interval [CI], 1.18–33.87, p = 0.03), while adults (>21 years) showed no significant difference between groups (RR, 1.48; 95% CI, 0.25–8.91, n.s.). Furthermore, DIS reoperation rates were significantly higher than respective ACLR rates (RR, 2.22; 95% CI, 1.35–3.65, p = 0.002), whereas BEAR (RR, 1.07; 95% CI, 0.41–2.75, n.s.) and ACLPR (RR, 0.81; 95% CI, 0.21–3.09, n.s.) showed no differences. IKDC scores were equivalent for all techniques. However, ACLPR exhibited significantly better FJS (mean difference, 11.93; 95% CI, 6.36–17.51, p < 0.0001) and Knee injury and Osteoarthritis Outcome Score Symptoms (mean difference, 3.01; 95% CI, 0.42–5.60, p = 0.02), along with a lower Tegner activity reduction.ConclusionsACLPR in skeletally mature patients ≤21 years of age is associated with up to a six‐fold risk increase for ACL revision surgery compared to ACLR; however, adults (>21 years) present no significant difference. Based on the current data, age emerges as a crucial risk factor and should be considered when deciding on the appropriate treatment option in proximal ACL tears.Level of EvidenceLevel III.

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The modern-day ACL surgeon's armamentarium should include multiple surgical approaches including primary repair, augmentation, and reconstruction: A letter to the Editor

Cited by 10 publications

References 21 publications

Management after acute injury of the anterior cruciate ligament (ACL). Part 3: Recommendation on surgical treatment

Management after acute injury of the anterior cruciate ligament (ACL). Part 3: Recommendation on surgical treatment

Refixation of the anterior cruciate ligament: A biomechanical analysis of suture techniques in a porcine model

Anterior cruciate ligament primary repair revision rates are increased in skeletally mature patients under the age of 21 compared to reconstruction, while adults (>21 years) show no significant difference: A systematic review and meta‐analysis

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