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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


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

Christof Hoffmann et al. J Orthop Surg Res.


Background: Current studies demonstrate encouraging short-term results after primary anterior cruciate ligament (ACL) suture anchor repair. However, earlier studies reported deterioration of knee function at 5-year follow-up following good clinical short-term recovery. Therefore, the aim of this study was to evaluate clinical long-term results after primary ACL repair at a minimum 5-year follow-up.

Methods: In a retrospective study, 13 patients were included between 2009 and 2012. Inclusion criteria were an acute proximal, femoral avulsion tear of the ACL with good tissue quality and sagittal instability in a healthy, demanding patient. Patients suffering proximal tibial fractures, arthrosis, or multiligamentous injuries of the knee were excluded. The ACL was anchored to the footprint by a single 2.9-mm push lock anchor, followed by additional microfracturing. For follow-up, patients were evaluated according to Lysholm score, modified Cincinnati score, and Tegner activity score. Clinical examination was performed using Lachman and pivot-shift testing and range of motion and sagittal stability measurement, using a Rolimeter.

Results: Mean follow-up was 79 (range 60 to 98) months. One patient was lost to follow-up, and 11 out of 12 patients were examined clinically. Eight patients achieved good subjective and clinical outcome. One patient suffered an early re-tear, and one patient with additional patellar tendon tear and one patient with polyarthritis demonstrated poor subjective and clinical results due to lasting instability. Seven out of 12 patients reached preoperative Tegner activity score postoperatively again. The mean Lysholm score was 85.3 points, mean subjective IKDC score was 87.3 points, and mean modified Cincinnati score was 83.8 points. Rolimeter measurements demonstrated a mean side-to-side difference of 2 (range 1-5) mm.

Conclusion: In the current study, primary surgical re-fixation of proximal, femoral ACL avulsion tears using single suture anchor repair resulted in good to excellent clinical mid-term outcomes. However, in cases of additional serious damage to extensor structures or systemic rheumatic disease, loss of function and unsatisfying clinical results occurred. Further prospective randomized controlled trials are necessary to confirm the encouraging long-term results of this study.

Trial registration: Bavarian National Medical Chamber of Physicians, file number 2016-095. German Clinical Trials ( DRKS00013059 ).

Keywords: Anterior cruciate ligament (ACL); Mid-term follow-up; Single suture anchor re-fixation.

Conflict of interest statement

Ethics approval and consent to participate

All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments. The study was approved by the national review board (Review Board of the Bavarian National Medical Chamber of Physicians, file number 2016-095). All patients permitted written informed consent about ACL preservation and reconstruction techniques.

Consent for publication

Written informed consent was obtained from the patients for publication of this report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


Fig. 1
Fig. 1
Arthroscopic view of a left knee with proximal avulsion tear of the ACL. The antero-medial bundle is mounted utilizing a no. 2 Fiber Wire, the postero-lateral bundle using a no. 0 Fiber Wire. The image was taken before the second stich through the postero-lateral bundle. Image no. 2 shows the final result after femoral ACL re-fixation
Fig. 2
Fig. 2
Mid-term results of postoperative Tegner activity score compared to preoperative activity level
Fig. 3
Fig. 3
Mid-term functional outcome according to Lysholm, modified Cincinnati, and subjective IKDC scores
Fig. 4
Fig. 4
MRI scan of a 26-year-old male patient 2 years after primary arthroscopic suture anchor re-fixation of the ACL. The patient presented again in terms of a second injury including hyperextension of the knee. Up to this second injury, the patient was pain free and fully recovered to his preoperative sports level

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