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Anterior Cruciate Ligament Repair - Past, Present and Future


Anterior Cruciate Ligament Repair - Past, Present and Future

Piyush Mahapatra et al. J Exp Orthop.


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

Authors information

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).

Ethics approval and consent to participate

Not applicable.

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
Internal Brace Ligament Augmentation (Arthrex™)
Fig. 2
Fig. 2
Dynamic Intraligamentary Stabilisation (Mathys Medical™)

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