AANA Lab Course 913 - Advanced Knee Course-ACL Primary Repair_ Is There a Role_ Faculty Lecture

ACL Primary Repair_ Is There a Role_ Faculty Lecture_ William R. Beach, MD

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This document presents a comprehensive overview of primary anterior cruciate ligament (ACL) repair, particularly in young, athletic patients. It begins with a case of a 16-year-old female athlete requiring urgent ACL repair to return to competition within five months. Key findings include a femoral ACL avulsion, a medial meniscal tear, and patellar mal-tracking.<br /><br />Historically, ACL repair was first performed in 1895 by Sir Arthur Mayo-Robson, evolving through the 20th century with open repair techniques; however, reconstruction eventually became favored. Despite historically mixed outcomes, recent systematic reviews highlight that primary ACL repair, especially with internal suture bracing and biological augmentation (e.g., collagen-platelet composites), yields improved healing and biomechanical strength. Younger, skeletally immature patients show better histologic and biomechanical recovery.<br /><br />Long-term studies show mixed results. One 10-year prospective study of 50 patients with partial ACL tears undergoing primary repair and marrow stimulation found good to excellent outcomes when secondary ACL insufficiency was absent; however, 27% experienced insufficiency. Twenty-year follow-ups reveal a 28% rate of further ACL injury after reconstruction, higher in younger patients and those with increased posterior tibial slope, but no clear link to osteoarthritis.<br /><br />Secondary ACL injury rates remain high after ACL reconstruction, with nearly 25% of athletes under 25 reinjuring their ACL, often early after return to play. This raises questions about the equivalence of repair and reconstruction regarding outcomes.<br /><br />Recent advancements include internal bracing and biological augmentation techniques that enhance primary repair success, especially in proximal ACL tears in young patients. Compared to reconstruction, repair may better preserve the native ligament’s neurosensory pathways, potentially improving functional recovery and reducing pain with faster rehabilitation.<br /><br />Overall, primary ACL repair, combined with modern augmentation methods, offers a promising alternative to reconstruction in selected young patients with acute proximal tears, aiming to restore knee stability, preserve proprioception, and facilitate quicker return to sport.

Keywords

primary ACL repair

anterior cruciate ligament

young athletes

internal suture bracing

biological augmentation

collagen-platelet composites

ACL reconstruction

secondary ACL injury

patellar mal-tracking

proprioception preservation