Summary

Although the historical outcomes of open primary repair deteriorated at mid-term follow-up, the results in this study indicate that the outcomes of arthroscopic primary repair of proximal ACL tears remain excellent at mid-term follow-up.

Abstract

Introduction

Open primary repair of the anterior cruciate ligament (ACL) was the most common surgical treatment for ACL injuries in the 1970s and 1980s. Although the short-term outcomes of open primary repair were excellent, the results deteriorated at mid-term follow-up. Consequently, the surgical technique of open primary ACL repair was abandoned and ACL reconstruction became the gold standard of surgical treatment of ACL injuries.
Recently, excellent short-term outcomes of arthroscopic primary repair in patients with proximal ACL tears have been reported, but no studies have assessed if the outcomes deteriorate at mid-term follow-up. The goal of this study is therefore to assess the outcomes of this technique at mid-term follow-up. The hypothesis was that no deterioration in outcomes would be seen.

Methods

The first 11 consecutive patients with proximal avulsion tears and excellent tissue quality treated with arthroscopic primary repair were retrospectively evaluated. The outcomes of these patients at short-term follow-up have been reported with one failure (9%) and good clinical outcomes. With the initial primary repair surgery, two sutures were passed through the anteromedial and posterolateral bundle from distal to proximal in an alternating, locking Bunnel-type pattern and suture anchors were then used to approximate both bundles towards their original femoral footprints.
At the clinic visit at mid-term follow-up, physical examination, laxity examination and objective IKDC examinations were performed and patients were asked to complete the Lysholm, modified Cincinnati, SANE, Tegner and subjective IKDC questionnaires.

Results

Eleven patients were seen at mean follow-up of 5.6 years (range: 4.2–8.4 years). No patients had failure of the repair besides the person that already failed at the short-term follow-up (9%). One additional patient (9%) underwent reoperation for a medial meniscus tear and the ACL was functioning and most fibers were intact.
The other ten patients had full range of motion, a negative Lachman test, eight patients had a negative pivot shift and two patients +1 pivot shift. IKDC objective score was graded A in 8 patients and B in 2 patients. Mean Lysholm was 95 (range 79-100), mean modified Cincinnati 95 (range 77-100), mean SANE score 94 (range 75-100), preinjury Tegner 7.0 (range 5-9), and postoperative Tegner 6.7 (range 3-9), and IKDC subjective score 81 (range 52-100). Seven patients had a MRI that showed continuity of the ligament.

Conclusions

Historically, studies had shown that the results of open primary repair deteriorated at mid-term follow-up, which led to the abandonment of primary repair in all patients. With appropriate patient selection (only treating patients with proximal tears and excellent tissue quality) and an arthroscopic technique, results in this study did not deteriorate at mid-term follow-up. Arthroscopic primary repair of proximal ACL tears is an excellent, minimally invasive treatment option when used for a select group of patients.