Arthroscopic primary repair of proximal anterior cruciate ligament tears seems safe but higher level of evidence is needed: a systematic review and meta-analysis of recent literature

Abstract

Purpose To assess the outcomes of the various techniques of primary repair of proximal anterior cruciate ligament (ACL) tears in the recent literature using a systematic review with meta-analysis. Methods PRISMA guidelines were followed. All studies reporting outcomes of arthroscopic primary repair of proximal ACL tears using primary repair, repair with static (suture) augmentation and dynamic augmentation between January 2014 and July 2019 in PubMed, Embase and Cochrane were identified and included. Primary outcomes were failure rates and reoperation rates, and secondary outcomes were patient-reported outcome scores. Results A total of 13 studies and 1,101 patients (mean age 31 years, mean follow-up 2.1 years, 60% male) were included. Nearly all studies were retrospective studies without a control group and only one randomized study was identified. Grade of recommendation for primary repair was weak. There were 9 out of 74 failures following primary repair (10%), 6 out of 69 following repair with static augmentation (7%) and 106 out of 958 following dynamic augmentation (11%). Repair with dynamic augmentation had more reoperations (99; 10%), and more hardware removal (255; 29%) compared to the other procedures. All functional outcome scores were > 85% of maximum scores. Conclusions This systematic review with meta-analysis found that the different techniques of primary repair are safe with failure rates of 7-11%, no complications and functional outcome scores of > 85% of maximum scores. There was a high risk of bias and follow-up was short with 2.1 years. Prospective studies comparing the outcomes to ACL reconstruction with sufficient follow-up are needed prior to widespread implementation. Level of evidence IV.

The healing potential of an acutely repaired ACL: a sequential MRI study

“…However, note that this review included some long-term follow-up studies from the nonselective open repair days, likely limiting the applicability of their conclusions. Regardless, both studies stressed the obvious lack of long-term studies on the modern technique of arthroscopic ACL repair [9,31]. It is felt that it is early in the resurgence of interest in ACL primary repair and that, as indications and techniques evolve, our understanding and outcomes will improve proportionately.…”

“…Recently, taking advantage of modern arthroscopic surgical techniques, materials, and devices, there has been a renewed interest in primary repair of ACL. In the last several years, some studies on ACL repair have shown good to excellent results with a failure rate ranging from 7% to 15% of cases [9][10][11][12][13]. Most articles recommend surgery within 4 weeks from injury; however, there is a wide variety of delay until treatment, including at least one case report of a patient treated 11 years after injury [14].…”

The multiple ligament-injured knee: When is primary repair an option?

“…Historically, high failure rates of primary repair of both cruciate and collateral ligaments have been reported [21][22][23]. With increased awareness of the importance of patient selection by only performing repairs on proximal or distal type tears that can be reapproximated to their insertion, and the recent developments of additional suture augmentation, which is thought to protect the repaired ligament during rehabilitation, better outcomes of primary repair have been reported [24][25][26][27]. However, concern remains regarding this procedure as high failure rates of anterior cruciate ligament (ACL) repair have been reported among adolescents [28], while much less is known regarding posterior cruciate ligament (PCL) repair as the literature is scarce [29][30][31].…”

To heal or not to heal: the ACL dilemma

“…Returning to recently published literature on ACL repair, we notice that reported results are highly conflicting, with acceptable outcomes ranging from 40% to up to 90%. [ 17 – 20 ]. This great variability could be explained by the great variety of indications, surgical techniques, materials, and rehabilitation protocols.…”