Background: This article provides a detailed narrative review on the history and current concepts surrounding ligamentous repair techniques in athletic patients. In particular, we will focus on the anterior cruciate ligament (ACL) as a case study in ligament injury and ligamentous repair techniques. PubMed (MEDLINE), EMBASE and Cochrane Library databases for papers relating to primary anterior cruciate ligament reconstruction were searched by all participating authors. All relevant historical papers were included for analysis. Additional searches of the same databases were made for papers relating to biological enhancement of ligament healing.
Current standard: The poor capacity of the ACL to heal is one of the main reasons why the current gold standard surgical treatment for an ACL injury in an athletic patient is ACL reconstruction with autograft from either the hamstrings or patella tendon. It is hypothesised that by preserving and repairing native tissues and negating the need for autograft that primary ACL repair may represent a key step change in the treatment of ACL injuries.
History of primary acl repair: The history of primary ACL repair will be discussed and the circumstances that led to the near-abandonment of primary ACL repair techniques will be reviewed.
New primary repair techniques: There has been a recent resurgence in interest with regards to primary ACL repair. Improvements in imaging now allow for identification of tear location, with femoral-sided injuries, being more suitable for repair. We will discuss in details strategies for improving the mechanical and biological environment in order to allow primary healing to occur. In particular, we will explain mechanical supplementation such as Internal Brace Ligament Augmentation and Dynamic Intraligamentary Stabilisation techniques. These are novel techniques that aim to protect the primary repair by providing a stabilising construct that connects the femur and the tibia, thus bridging the repair.
Bio enhanced repair: In addition, biological supplementation is being investigated as an adjunct and we will review the current literature with regards to bio-enhancement in the form platelet rich plasma, bio-scaffolds and stem cells. On the basis of current evidence, there appears to be a role for bio-enhancement, however, this is not yet translated into clinical practice.
Conclusions: Several promising avenues of further research now exist in the form of mechanical and biological augmentation techniques. Further work is clearly needed but there is renewed interest and focus for primary ACL repair that may yet prove the new frontier in ligament repair.
Keywords: Anterior; Athletes; Cruciate; Ligament; Primary; Reconstruction; Repair.
Conflict of interest statement
PM is a specialist registrar in Trauma and Orthopaedics on the North West Thames Training Programme. He holds a MA from the University of Cambridge having completed his research in Clinical Pharmacology. He qualified with MBBS (Distinction) from University College London Medical School.
SM is a specialist registrar in Trauma and Orthopaedics on the South West Thames Training Programme. He holds a MD and MSc and his research interests focus on new frontiers in Trauma and Orthopaedic Surgery including the use of stem cells. He has authored a book chapter on the use of Bone Marrow Aspirate Concentrate in tendon pathologies.
BA is an orthopaedic surgeon specialising exclusively in knee surgery. He has a particular interest in sports knee injuries, anterior knee pain and optimising return to sport. He studied Medicine at University College London and graduated in 2002. In addition to his medical degree, he completed a degree (BSc) in Orthopaedic Science at the Royal National Orthopaedic Hospital. His specialist orthopaedic training was in Cambridge and London. He was made a fellow of the Royal College of Surgeons in 2011 and obtained his specialist CCT in 2013. BA in as invited committee member to the European Society for Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA).
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Anterior Cruciate Ligament Repair With Internal Brace Ligament AugmentationWT Wilson et al. Surg Technol Int 29, 273-278. PMID 27728954. - Case ReportsRepair with internal bracing of the ACL provides an unobtrusive support which allows accelerated recovery. In this case, we demonstrate with radiographic and arthroscopic …
Biologic Approaches for the Treatment of Partial Tears of the Anterior Cruciate Ligament: A Current Concepts ReviewI Dallo et al. Orthop J Sports Med 5 (1), 2325967116681724. PMID 28210653.The potential benefits of these biological augmentation approaches for partial ACL tears are improved healing, better proprioception, and a faster return to sport and act …
MRI Following Primary Repair of the Anterior Cruciate LigamentE De Smet et al. Clin Radiol 74 (8), 649.e1-649.e10. PMID 31072592. - ReviewPrimary repair of the anterior cruciate ligament (ACL) is being performed increasingly in the treatment of acute proximal ACL ruptures. Advantages of ACL repair over surg …
Primary Anterior Cruciate Ligament Single-Bundle Repair With Augmentation for a Partial Anterior Cruciate Ligament TearAM Gipsman et al. Arthrosc Tech 7 (4), e367-e372. PMID 29868406.Although anterior cruciate ligament (ACL) reconstruction remains the gold standard for the treatment of ACL tears, repair is regaining popularity as a treatment option fo …
A Narrative Review of Four Different New Techniques in Primary Anterior Cruciate Ligament Repair: "Back to the Future" or Another Trend?MA Malahias et al. Sports Med Open 4 (1), 37. PMID 30094753. - ReviewRecently, four different operative techniques, referring to the primary anterior cruciate ligament (ACL) repair, were described. These are the dynamic intraligamentary st …
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Anatomic Considerations in Hamstring Tendon Harvesting for Ligament ReconstructionA Olivos-Meza et al. Arthrosc Tech 9 (1), e191-e198. PMID 32021795.Hamstring tendon autograft remains a popular graft choice for anterior cruciate ligament reconstruction. Although the technique of hamstring autograft harvest is relative …
Anterior Cruciate Ligament Reconstruction With Suture Tape Augmentation: A Surgical TechniqueSR Anderson et al. Arthrosc Tech 8 (12), e1579-e1582. PMID 31890540.The anterior cruciate ligament (ACL) is the most common ligamentous knee injury and often is encountered in those participating in multidirectional sports. ACL reconstruc …
[Comparable Results After Arthroscopic Replacement of the Anterior Cruciate Ligament : Clinical and Functional Results After Single Bundle and Double Bundle Reconstruction]M Janko et al. Chirurg 91 (1), 67-75. PMID 31642938.Based on the results of this study it is currently not possible to give any recommendations regarding any operating procedure after a follow-up period of at least 12 mont …
CORR® International - Asia-Pacific: Stem Cell-based Treatments in Orthopaedic Clinical Practice-Is It Ready For Primetime in the Asia-Pacific Region?TK Kim. Clin Orthop Relat Res 477 (4), 695-697. PMID 30829690.
[Combined Posterior and Anterior Cruciate Ligament Reconstruction : Arthroscopic Treatment With the GraftLink® System]A Ateschrang et al. Oper Orthop Traumatol 31 (1), 20-35. PMID 30564843. - ReviewThe GraftLink® system allows restoration of knee joint stability with good functional results. The procedure is especially suitable for complex situations like after knee …
- Adravanti P, Dini F, de Girolamo L et al (2017) Single-bundle versus double-bundle anterior cruciate ligament reconstruction: a prospective randomized controlled trial with 6-year follow-up. J Knee Surg. 10.1055/s-0037-1598176 - PubMed
- Andersson C, Odensten M, Gillquist J (1991) Knee function after surgical or nonsurgical treatment of acute rupture of the anterior cruciate ligament: a randomized study with a long-term follow-up period. Clin Orthop Relat Res:255–263 - PubMed