Systematic Review| Volume 35, ISSUE 7, P2233-2247, July 2019

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Anterior Cruciate Ligament Repair Outcomes: An Updated Systematic Review of Recent Literature


      To critically review recent literature on outcomes following primary surgical repair of the anterior cruciate ligament (ACL).


      In December 2018, a search of the MEDLINE database was conducted for English language articles reporting clinical outcomes of ACL repair from 2003 to 2018. Included studies were evaluated for patient demographics, patient-reported outcome measures, return to sports/work, patient satisfaction, and postoperative complications. Subgroup analysis was conducted for studies that included patients with only type 1/proximal ACL ruptures.


      Twenty-eight studies satisfied the inclusion criteria, comprising 2,401 patients (52.3% male, 35.7% female, 12.0% unspecified gender) with mean age ranging from 6.0 to 43.3 years. Most studies were conducted in Europe (82.1%), were level of evidence IV (60.7%), and were designed as case series (57.1%). Fourteen investigations (50.0%) used primary suture repair and 14 (50.0%) used dynamic intraligamentary stabilization. Preoperative ranges for Lysholm, International Knee Documentation Committee Score subjective, and Tegner scores were 28 to 100, 94.1 to 100, and 2 to 9, respectively. Postoperative ranges for the same measures were 80 to 100, 54.3 to 98, and 3.67 to 7, respectively. Time to return to sport/work ranged from 3.1 ± 3.3 to 17.4 ± 1.5 weeks. Frequency of rerupture, revision ACL surgery, and overall reoperations were as high as 23.1%, 33.3%, and 51.5%, respectively. Overall ACL repair survivorship ranged from 60.0% to 100.0%. In subgroup analysis for proximal ruptures treated with repair, the rates of revision ACL reconstruction (ACLR) and total reoperations were as high as 12.9% and 18.2%, respectively.


      Based on our cumulative findings across 2,401 patients from the 28 included studies, it appears that ACLR results in better survivorship and patient-perceived postoperative improvement when compared with ACL repair. At present, ACLR appears to remain the superior treatment strategy in the vast majority of cases.

      Level of Evidence

      Level IV, systematic review of Level II to IV studies.
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        • Sanders T.L.
        • Maradit Kremers H.
        • Bryan A.J.
        • et al.
        Incidence of anterior cruciate ligament tears and reconstruction: A 21-year population-based study.
        Am J Sports Med. 2016; 44: 1502-1507
        • 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
        • Feagin 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
        • Kaplan N.
        • Wickiewicz T.L.
        • Warren R.F.
        Primary surgical treatment of anterior cruciate ligament ruptures: A long-term follow-up study.
        Am J Sports Med. 1990; 18: 354-358
        • Lysholm J.
        • Gjllquist J.
        • Liljedahl S.-O.
        Long-term results after early treatment of knee injuries.
        Acta Orthop Scand. 1982; 53: 109-118
        • 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
        • 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
        • Lyman S.
        • Koulouvaris P.
        • Sherman S.
        • Do H.
        • Mandl L.A.
        • Marx R.G.
        Epidemiology of anterior cruciate ligament reconstruction: Trends, readmissions, and subsequent knee surgery.
        J Bone Joint Surg Am. 2009; 91: 2321-2328
        • Mall N.A.
        • Chalmers P.N.
        • Moric M.
        • et al.
        Incidence and trends of anterior cruciate ligament reconstruction in the United States.
        Am J Sports Med. 2014; 41: 2326-2370
        • Leiter J.R.
        • Gourlay R.
        • McRae S.
        • de Korompay N.
        • MacDonald P.B.
        Long-term follow-up of ACL reconstruction with hamstring autograft.
        Knee Surg Sports Traumatol Arthrosc. 2014; 22: 1061-1069
        • Nwachukwu B.U.
        • Voleti P.B.
        • Berkanish P.
        • et al.
        Return to play and patient satisfaction after ACL reconstruction: Study with minimum 2-year follow-up.
        J Bone Joint Surg Am. 2017; 99: 720-725
        • Poehling-Monaghan K.L.
        • Salem H.
        • Ross K.E.
        • et al.
        Long-term outcomes in anterior cruciate ligament reconstruction: A systematic review of patellar tendon versus hamstring autografts.
        Orthop J Sports Med. 2017; 5 (2325967117709735)
        • van der List J.P.
        • DiFelice G.S.
        Primary repair of the anterior cruciate ligament: A paradigm shift.
        Surgeon. 2017; 15: 161-168
        • DiFelice G.S.
        • Villegas C.
        • Taylor S.
        Anterior cruciate ligament preservation: Early results of a novel arthroscopic technique for suture anchor primary anterior cruciate ligament repair.
        Arthroscopy. 2015; 31: 2162-2171
        • DiFelice G.S.
        • van der List J.P.
        Clinical outcomes of arthroscopic primary repair of proximal anterior cruciate ligament tears are maintained at mid-term follow-up.
        Arthroscopy. 2018; 34: 1085-1093
        • Higgins J.
        • Sterne J.A.C.
        • Savovic J.
        • et al.
        A revised tool for assessing risk of bias in randomized trials.
        Cochrane Methods/Cochrane Database of Syst Rev. 2016; 2016
        • Achtnich A.
        • Herbst E.
        • Forkel P.
        • et al.
        Acute proximal anterior cruciate ligament tears: Outcomes after arthroscopic suture anchor repair versus anatomic single-bundle reconstruction.
        Arthroscopy. 2016; 32: 2562-2569
        • Ateschrang A.
        • Ahmad S.S.
        • Stöckle U.
        • Schroeter S.
        • Schenk W.
        • Ahrend M.D.
        Recovery of ACL function after dynamic intraligamentary stabilization is resultant to restoration of ACL integrity and scar tissue formation.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 589-595
        • Barzegar H.
        • Mohseni M.
        • Sedighi A.
        • Shahsavari A.
        • Mohammadpour H.
        Arthroscopically-assisted vs. open surgery in repairing anterior cruciate ligament avulsion.
        Pakistan J Biol Sci. 2011; 15: 496-501
        • Bigoni M.
        • Gaddi D.
        • Gorla M.
        • et al.
        Arthroscopic anterior cruciate ligament repair for proximal anterior cruciate ligament tears in skeletally immature patients: Surgical technique and preliminary results.
        Knee. 2017; 24: 40-48
        • Heusdens C.H.W.
        • Hopper G.P.
        • Dossche L.
        • Roelant E.
        • Mackay G.M.
        Anterior cruciate ligament repair with independent suture tape reinforcement: A case series with 2-year follow-up.
        Knee Surg Sports Traumatol Arthrosc. 2019; 27: 60-67
        • Hoffmann C.
        • Friederichs J.
        • von Ruden C.
        • Schaller C.
        • Buhren V.
        • Moessmer C.
        Primary single suture anchor re-fixation of anterior cruciate ligament proximal avulsion tears leads to good functional mid-term results: A preliminary study in 12 patients.
        J Orthop Surg Res. 2017; 12: 171
        • Mukhopadhyay R.
        • Shah N.
        • Vakta R.
        • Bhatt J.
        ACL femoral avulsion repair using suture pull-out technique: A case series of thirteen patients.
        Chinese J Traumatol. 2018; 21: 352-355
        • van der List J.P.
        • DiFelice G.S.
        Range of motion and complications following primary repair versus reconstruction of the anterior cruciate ligament.
        Knee. 2017; 24: 798-807
        • Ateschrang A.
        • Schreiner A.J.
        • Ahmad S.S.
        • et al.
        Improved results of ACL primary repair in one-part tears with intact synovial coverage.
        Knee Surg Sports Traumatol Arthrosc. 2018; 27: 37-43
        • Slim K.
        • Nini E.
        • Forestier D.
        • Kwiatkowski F.
        • Panis Y.
        • Chipponi J.
        Methodological Index for Non-randomized Sstudies (MINORS): Development and validation of a new instrument.
        ANZ J Surg. 2003; 73: 712-716
        • Sterne J.A.
        • Hernán M.A.
        • Reeves B.C.
        • et al.
        ROBINS-I: A tool for assessing risk of bias in non-randomised studies of interventions.
        Br Med J. 2016; 355
        • Bieri K.S.
        • Scholz S.M.
        • Kohl S.
        • Aghayev E.
        • Staub L.P.
        Dynamic intraligamentary stabilization versus conventional ACL reconstruction: A matched study on return to work.
        Injury. 2017; 48: 1243-1248
        • Buchler L.
        • Regli D.
        • Evangelopoulos D.S.
        • et al.
        Functional recovery following primary ACL repair with dynamic intraligamentary stabilization.
        Knee. 2016; 23: 549-553
        • Drogset J.O.
        • Grøntvedt T.
        • Robak O.R.
        • Mølster A.
        • Viset A.T.
        • Engebretsen L.
        A sixteen-year follow-up of 3 operative techniques for the treatment of acute ruptures of the anterior cruciate ligament.
        J Bone Joint Surg Am. 2006; 88: 944-952
        • Eggli S.
        • Kohlhof H.
        • Zumstein M.
        • et al.
        Dynamic intraligamentary stabilization: Novel technique for preserving the ruptured ACL.
        Knee Surg Sports Traumatol Arthrosc. 2015; 23: 1215-1221
        • Evangelopoulos D.S.
        • Kohl S.
        • Schwienbacher S.
        • Gantenbein B.
        • Exadaktylos A.
        • Ahmad S.S.
        Collagen application reduces complication rates of mid-substance ACL tears treated with dynamic intraligamentary stabilization.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 2414-2419
        • 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
        • Haberli J.
        • Jaberg L.
        • Bieri K.
        • Eggli S.
        • Henle P.
        Reinterventions after dynamic intraligamentary stabilization in primary anterior cruciate ligament repair.
        Knee. 2018; 25: 271-278
        • Henle P.
        • Bieri K.S.
        • Brand M.
        • et al.
        Patient and surgical characteristics that affect revision risk in dynamic intraligamentary stabilization of the anterior cruciate ligament.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 1182-1189
        • Henle P.
        • Roder C.
        • Perler G.
        • Heitkemper S.
        • Eggli S.
        Dynamic intraligamentary stabilization (DIS) for treatment of acute anterior cruciate ligament ruptures: Case series experience of the first three years.
        BMC Muskuloskel Disord. 2015; 16
        • Kohl S.
        • Evangelopoulos D.S.
        • Schar M.O.
        • Bieri K.
        • Muller T.
        • Ahmad S.S.
        Dynamic intraligamentary stabilisation: initial experience with treatment of acute ACL ruptures.
        Bone Joint J. 2016; 98: 793-798
        • Krismer A.M.
        • Gousopoulos L.
        • Kohl S.
        • Ateschrang A.
        • Kohlhof H.
        • Ahmad S.S.
        Factors influencing the success of anterior cruciate ligament repair with dynamic intraligamentary stabilisation.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 3923-3928
        • Meister M.
        • Koch J.
        • Amsler F.
        • Arnold M.P.
        • Hirschmann M.T.
        ACL suturing using dynamic intraligamentary stabilisation showing good clinical outcome but a high reoperation rate: A retrospective independent study.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 655-659
        • Murray M.M.
        • Flutie B.M.
        • Kalish L.A.
        • et al.
        The bridge-enhanced anterior cruciate ligament repair (BEAR) procedure: An early feasibility cohort study.
        Orthop J Sports Med. 2016; 4
        • Schliemann B.
        • Glasbrenner J.
        • Rosenbaum D.
        • et al.
        Changes in gait pattern and early functional results after ACL repair are comparable to those of ACL reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 374-380
        • Smith J.O.
        • Yasen S.K.
        • Palmer H.C.
        • Lord B.R.
        • Britton E.M.
        • Wilson A.J.
        Paediatric ACL repair reinforced with temporary internal bracing.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 1845-1851
        • 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
        • 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
        • Osti M.
        • El Attal R.
        • Doskar W.
        • Hock P.
        • Smekal V.
        High complication rate following dynamic intraligamentary stabilization for primary repair of the anterior cruciate ligament.
        Knee Surg Sports Traumatol Arthrosc. 2019; 27: 29-36
        • Taylor S.A.
        • Khair M.M.
        • Roberts T.R.
        • DiFelice G.S.
        Primary repair of the anterior cruciate ligament: A systematic review.
        Arthroscopy. 2015; 31: 2233-2247
        • Andernord D.
        • Desai N.
        • Björnsson H.
        • Ylander M.
        • Karlsson J.
        • Samuelsson K.
        Patient predictors of early revision surgery after anterior cruciate ligament reconstruction: A cohort study of 16,930 patients with 2-year follow-up.
        Am J Sports Med. 2014; 43: 121-127
        • Kaeding C.C.
        • Pedroza A.D.
        • Reinke E.K.
        • Huston L.J.
        • Spindler K.P.
        Risk factors and predictors of subsequent ACL injury in either knee after ACL reconstruction: Prospective analysis of 2488 primary ACL reconstructions from the MOON cohort.
        Am J Sports Med. 2015; 43: 1583-1590
        • Tejwani S.G.
        • Chen J.
        • Funahashi T.T.
        • Love R.
        • Maletis G.B.
        Revision risk after allograft anterior cruciate ligament reconstruction: Association with graft processing techniques, patient characteristics, and graft type.
        Am J Sports Med. 2015; 43: 2696-2705
        • Crawford S.N.
        • Waterman B.R.
        • Lubowitz J.H.
        Long-term failure of anterior cruciate ligament reconstruction.
        Arthroscopy. 2013; 29: 1566-1571
        • Riff A.J.
        • Luchetti T.J.
        • Weber A.E.
        • Chahal J.
        • Bach Jr., B.R.
        Thirty-year experience with ACL reconstruction using patellar tendon: A critical evaluation of revision and reoperation.
        Orthop J Sports Med. 2017; 5 (2325967117724345)
        • Magnussen R.A.
        • Verlage M.
        • Flanigan D.C.
        • Kaeding C.C.
        • Spindler K.P.
        Patient-reported outcomes and their predictors at minimum 10 years after anterior cruciate ligament reconstruction: A systematic review of prospectively collected data.
        Orthop J Sports Med. 2015; 3 (2325967115573706)

      Linked Article

      • Editorial Commentary: Back to the Past—Anterior Cruciate Ligament Repair Revisited
        ArthroscopyVol. 35Issue 7
        • Preview
          There has been increasing scientific interest in primary anterior cruciate ligament (ACL) repair in recent years. The results of these procedures have improved significantly compared with the 1970s and 1980s. Nevertheless, the overall rerupture rates after ACL repair are worse than after ACL reconstruction, and patient-reported outcome measures do not improve after ACL repair, in contrast to those after ACL reconstruction. However, because primary ACL repair is performed in the acute phase, improvement in patient-reported outcome measures after surgery is not expected.
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