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Primary Repair of the Anterior Cruciate Ligament: A Systematic Review

      Purpose

      To describe the clinical and preclinical research conducted on primary repair of the anterior cruciate ligament (ACL) during the past 10 years.

      Methods

      A systematic search of PubMed, the Cochrane Central Register of Controlled Trials, and Embase was performed for all English-language studies published between 2003 and April 2014 on primary repair of the ACL.

      Results

      Twenty-six studies met the inclusion and exclusion criteria. In the clinical research group, 8 studies (166 patients; age range, 10 to 71 years) met the inclusion and exclusion criteria and were largely long-term clinical outcome studies, based on the original cohorts from the 1970s and 1980s, and suggested high failure rates, additional surgery, and revision for instability. A subset of patients, however, achieved good to excellent subjective and objective long-term outcomes. In the preclinical research group, 18 studies met the inclusion and exclusion criteria and were based on an ACL transection model; they suggested that (1) stabilization of the knee with an internal suture strut improved the healing and biomechanical properties of the repaired ACL, (2) “enhancing” the repair with biological collagen-platelet composite augmentation improved healing and mechanical strength, (3) younger age and skeletal immaturity seem to correlate with improved histologic healing and biomechanical properties, (4) enhanced primary repair of the ACL may reduce post-traumatic osteoarthritis, and (5) the native ACL biomechanically outperformed the repaired ACL.

      Conclusions

      Although long-term human studies suggest collectively unacceptable outcomes for open primary repair of the ACL, a subset of patients achieved acceptable long-term results. ACL transection model animal studies showed improved healing and biomechanics with primary suture repair stabilization, early intervention, biological augmentation techniques, and younger age. Primary repair of the ACL may be an effective treatment modality for an appropriately selected subset of patients.

      Level of Evidence

      Level IV, systematic review of preclinical and clinical Level IV studies.
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      References

        • Robson A.W.
        VI. Ruptured crucial ligaments and their repair by operation.
        Ann Surg. 1903; 37: 716-718
        • Liljedahl S.O.
        • Lindvall N.
        • Wetterfors J.
        Early diagnosis and treatment of acute ruptures of the anterior cruciate ligament; a clinical and arthrographic study of forty-eight cases.
        J Bone Joint Surg Am. 1965; 47: 1503-1513
        • O’Donoghue D.H.
        An analysis of end results of surgical treatment of major injuries to the ligaments of the knee.
        J Bone Joint Surg Am. 1955; 37 (passim): 13
        • Pringle J.H.
        I. Avulsion of the spine of the tibia.
        Ann Surg. 1907; 46: 169-178
        • England R.L.
        Repair of the ligaments about the knee.
        Orthop Clin North Am. 1976; 7: 195-204
        • Feagin J.A.
        • Abbott H.G.
        • Roukous J.A.
        The isolated tear of the ACL.
        J Bone Joint Surg Am. 1972; 54 (abstract): 1340
        • Feagin Jr., J.A.
        • Curl W.W.
        Isolated tear of the anterior cruciate ligament: 5-year follow-up study.
        Am J Sports Med. 1976; 4: 95-100
        • Odensten M.
        • Lysholm J.
        • Gillquist J.
        Suture of fresh ruptures of the anterior cruciate ligament. A 5-year follow-up.
        Acta Orthop Scand. 1984; 55: 270-272
        • Engebretsen L.
        • Benum P.
        • Sundalsvoll S.
        Primary suture of the anterior cruciate ligament. A 6-year follow-up of 74 cases.
        Acta Orthop Scand. 1989; 60: 561-564
        • Warren R.F.
        Primary repair of the anterior cruciate ligament.
        Clin Orthop Relat Res. 1983; : 65-70
        • Strand T.
        • Molster A.
        • Hordvik M.
        • Krukhaug Y.
        Long-term follow-up after primary repair of the anterior cruciate ligament: Clinical and radiological evaluation 15-23 years postoperatively.
        Arch Orthop Trauma Surg. 2005; 125: 217-221
        • Drogset J.O.
        • Grontvedt T.
        • Robak O.R.
        • Molster A.
        • Viset A.T.
        • Engebretsen L.
        A sixteen-year follow-up of three operative techniques for the treatment of acute ruptures of the anterior cruciate ligament.
        J Bone Joint Surg Am. 2006; 88: 944-952
        • Taylor D.C.
        • Posner M.
        • Curl W.W.
        • Feagin J.A.
        Isolated tears of the anterior cruciate ligament: Over 30-year follow-up of patients treated with arthrotomy and primary repair.
        Am J Sports Med. 2009; 37: 65-71
        • Grontvedt T.
        • Engebretsen L.
        • Benum P.
        • Fasting O.
        • Molster A.
        • Strand T.
        A prospective, randomized study of three operations for acute rupture of the anterior cruciate ligament. Five-year follow-up of one hundred and thirty-one patients.
        J Bone Joint Surg Am. 1996; 78: 159-168
        • Meunier A.
        • Odensten M.
        • Good L.
        Long-term results after primary repair or non-surgical treatment of anterior cruciate ligament rupture: A randomized study with a 15-year follow-up.
        Scand J Med Sci Sports. 2007; 17: 230-237
        • Arbes S.
        • Resinger C.
        • Vecsei V.
        • Nau T.
        The functional outcome of total tears of the anterior cruciate ligament (ACL) in the skeletally immature patient.
        Int Orthop. 2007; 31: 471-475
        • Toy J.O.
        • Feeley B.T.
        • Gulotta L.V.
        • Warren R.F.
        Arthroscopic avulsion repair of a pediatric ACL with an anomalous primary insertion into the lateral meniscus.
        HSS J. 2011; 7: 190-193
        • Gaulrapp H.M.
        • Haus J.
        Intraarticular stabilization after anterior cruciate ligament tear in children and adolescents: Results 6 years after surgery.
        Knee Surg Sports Traumatol Arthrosc. 2006; 14: 417-424
        • Ahn J.H.
        • Han K.Y.
        • Yu I.S.
        • Koh K.H.
        Arthroscopic treatment for tibial “peel off” tears in anterior cruciate ligament-case report.
        Eur J Orthop Surg Traumatol. 2013; 23 (suppl 2): S251-S255
        • Seitz H.
        • Menth-Chiari W.A.
        • Lang S.
        • Nau T.
        Histological evaluation of the healing potential of the anterior cruciate ligament by means of augmented and non-augmented repair: An in vivo animal study.
        Knee Surg Sports Traumatol Arthrosc. 2008; 16: 1087-1093
        • Fisher M.B.
        • Jung H.J.
        • McMahon P.J.
        • Woo S.L.
        Evaluation of bone tunnel placement for suture augmentation of an injured anterior cruciate ligament: Effects on joint stability in a goat model.
        J Orthop Res. 2010; 28: 1373-1379
        • Fisher M.B.
        • Jung H.J.
        • McMahon P.J.
        • Woo S.L.
        Suture augmentation following ACL injury to restore the function of the ACL, MCL, and medial meniscus in the goat stifle joint.
        J Biomech. 2011; 44: 1530-1535
        • Murray M.M.
        • Magarian E.
        • Zurakowski D.
        • Fleming B.C.
        Bone-to-bone fixation enhances functional healing of the porcine anterior cruciate ligament using a collagen-platelet composite.
        Arthroscopy. 2010; 26 (suppl): S49-S57
        • Seitz H.
        • Pichl W.
        • Matzi V.
        • Nau T.
        Biomechanical evaluation of augmented and nonaugmented primary repair of the anterior cruciate ligament: An in vivo animal study.
        Int Orthop. 2013; 37: 2305-2311
        • Fleming B.C.
        • Magarian E.M.
        • Harrison S.L.
        • Paller D.J.
        • Murray M.M.
        Collagen scaffold supplementation does not improve the functional properties of the repaired anterior cruciate ligament.
        J Orthop Res. 2010; 28: 703-709
        • Joshi S.M.
        • Mastrangelo A.N.
        • Magarian E.M.
        • Fleming B.C.
        • Murray M.M.
        Collagen-platelet composite enhances biomechanical and histologic healing of the porcine anterior cruciate ligament.
        Am J Sports Med. 2009; 37: 2401-2410
        • Fisher M.B.
        • Liang R.
        • Jung H.J.
        • et al.
        Potential of healing a transected anterior cruciate ligament with genetically modified extracellular matrix bioscaffolds in a goat model.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 1357-1365
        • Palmer M.P.
        • Abreu E.L.
        • Mastrangelo A.
        • Murray M.M.
        Injection temperature significantly affects in vitro and in vivo performance of collagen-platelet scaffolds.
        J Orthop Res. 2009; 27: 964-971
        • Magarian E.M.
        • Vavken P.
        • Connolly S.A.
        • Mastrangelo A.N.
        • Murray M.M.
        Safety of intra-articular use of atelocollagen for enhanced tissue repair.
        Open Orthop J. 2012; 6: 231-238
        • Murray M.M.
        • Spindler K.P.
        • Devin C.
        • et al.
        Use of a collagen-platelet rich plasma scaffold to stimulate healing of a central defect in the canine ACL.
        J Orthop Res. 2006; 24: 820-830
        • Murray M.M.
        • Spindler K.P.
        • Abreu E.
        • et al.
        Collagen-platelet rich plasma hydrogel enhances primary repair of the porcine anterior cruciate ligament.
        J Orthop Res. 2007; 25: 81-91
        • Murray M.M.
        • Palmer M.
        • Abreu E.
        • Spindler K.P.
        • Zurakowski D.
        • Fleming B.C.
        Platelet-rich plasma alone is not sufficient to enhance suture repair of the ACL in skeletally immature animals: An in vivo study.
        J Orthop Res. 2009; 27: 639-645
        • Mastrangelo A.N.
        • Vavken P.
        • Fleming B.C.
        • Harrison S.L.
        • Murray M.M.
        Reduced platelet concentration does not harm PRP effectiveness for ACL repair in a porcine in vivo model.
        J Orthop Res. 2011; 29: 1002-1007
        • Murray M.M.
        • Magarian E.M.
        • Harrison S.L.
        • Mastrangelo A.N.
        • Zurakowski D.
        • Fleming B.C.
        The effect of skeletal maturity on functional healing of the anterior cruciate ligament.
        J Bone Joint Surg Am. 2010; 92: 2039-2049
        • Vavken P.
        • Saad F.A.
        • Fleming B.C.
        • Murray M.M.
        VEGF receptor mRNA expression by ACL fibroblasts is associated with functional healing of the ACL.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 1675-1682
        • Haus B.M.
        • Mastrangelo A.N.
        • Murray M.M.
        Effect of anterior cruciate healing on the uninjured ligament insertion site.
        J Orthop Res. 2012; 30: 86-94
        • Magarian E.M.
        • Fleming B.C.
        • Harrison S.L.
        • Mastrangelo A.N.
        • Badger G.J.
        • Murray M.M.
        Delay of 2 or 6 weeks adversely affects the functional outcome of augmented primary repair of the porcine anterior cruciate ligament.
        Am J Sports Med. 2010; 38: 2528-2534
        • Vavken P.
        • Fleming B.C.
        • Mastrangelo A.N.
        • Machan J.T.
        • Murray M.M.
        Biomechanical outcomes after bioenhanced anterior cruciate ligament repair and anterior cruciate ligament reconstruction are equal in a porcine model.
        Arthroscopy. 2012; 28: 672-680
        • Murray M.M.
        • Fleming B.C.
        Use of a bioactive scaffold to stimulate anterior cruciate ligament healing also minimizes posttraumatic osteoarthritis after surgery.
        Am J Sports Med. 2013; 41: 1762-1770
        • Sherman M.F.
        • Lieber L.
        • Bonamo J.R.
        • Podesta L.
        • Reiter I.
        The long-term followup of primary anterior cruciate ligament repair. Defining a rationale for augmentation.
        Am J Sports Med. 1991; 19: 243-255
        • Wasmaier J.
        • Kubik-Huch R.
        • Pfirrmann C.
        • Grehn H.
        • Bieg C.
        • Eid K.
        Proximal anterior cruciate ligament tears: The healing response technique versus conservative treatment.
        J Knee Surg. 2013; 26: 263-271
        • Steadman J.R.
        • Cameron-Donaldson M.L.
        • Briggs K.K.
        • Rodkey W.G.
        A minimally invasive technique (“healing response”) to treat proximal ACL injuries in skeletally immature athletes.
        J Knee Surg. 2006; 19: 8-13
        • Nguyen D.T.
        • Geel J.
        • Schultze M.
        • et al.
        Healing of the goat anterior cruciate ligament after a new suture repair technique and bioscaffold treatment.
        Tissue Eng Part A. 2013; 19: 2292-2299