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Background: Anterior cruciate ligament suture repair (ACLSR) was abandoned late last century in favor of anterior cruciate ligament (ACL) reconstruction (ACLR) because of overall disappointing results. However, in recent years there has been renewed and increasing interest in ACLSR for treatment of ACL ruptures. Several contemporary ACLSR techniques are being used, but any difference in effectiveness is unclear. Hypothesis: Contemporary nonaugmented (NA), static augmented (SA), and dynamic augmented (DA) ACLSR leads to (1) comparable outcomes overall and (2) comparable outcomes between proximal third, middle third, and combined ACL rupture locations (a) within and (b) between ACLSR technique categories. Study Design: Systematic review. Methods: An electronic search was performed in the MEDLINE and Embase databases for the period between January 1, 2010, and August 7, 2019. All articles describing clinical and patient-reported outcomes for ACLSR were identified and included, and outcomes for NA, SA, and DA ACLSR categories were compared. Results: A total of 31 articles and 2422 patients were included. The majority of articles (65%) and patients (89%) reported outcomes of DA ACLSR. Overall, there was high heterogeneity in study characteristics and level as well as quality of evidence (19 level 4; 7 level 3; 3 level 2; and 2 level 1). Most studies indicated excellent patient-reported outcomes. Overall, the variability in (and the maximum of) the reported failure rate was high within all ACLSR categories. The variability in (and the maximum of) the reported rate of all other complications was highest for DA ACLSR. Regarding ACL rupture location, the failure rate was highest in proximal ACL ruptures within the SA and DA ACLSR categories; rates of all other reported complications were highest in combined ACL ruptures within the DA ACLSR category. However, no studies in the NA category and only 1 study in the SA ACLSR category evaluated combined ACL ruptures. The majority of studies comparing ACLSR and ACLR found no differences in outcomes. Conclusion: The amount of high-quality evidence for contemporary ACLSR is poor. This makes it difficult to interpret differences among ACLSR categories and among ACL rupture locations and, though promising, to establish the role of ACLSR in the treatment of ACL ruptures. More high-quality large randomized clinical trials with longer follow-up comparing ACLSR and ACLR are needed.

Background: High-level evidence for short–term outcomes of contemporary anterior cruciate ligament (ACL) suture repair (ACLSR) in comparison with those of ACL reconstruction (ACLR) is scarce. High-level evidence for mid- and long–term results is lacking, whereas outcomes of ACLSR in several historical studies were shown to deteriorate at midterm follow–up after initial good short–term outcomes. Hypothesis: Contemporary ACLSR is noninferior to ACLR in the treatment of acute ACL rupture in terms of patient self–reported outcomes at 5 years postoperatively. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 48 patients were enrolled in the study and, after stratification and randomization, underwent either dynamic augmented (DA) ACLSR or anatomic single–bundle ACLR. The primary outcome measure was the International Knee Documentation Committee 2000 (IKDC) subjective score (IKDCs). Furthermore, the Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner Activity Scale score (TAS), visual analog scale score for satisfaction (VASs), IKDC physical examination score (IKDCpe), limb symmetry index for quadriceps (LSIq) and hamstrings (LSIh) strength and jump test battery (LSIj), Kellgren-Lawrence grade of osteoarthritis (OA), and rate of adverse events were recorded. Analyses were based on an intention–to–treat principle. Results: The lower limit of the 2–sided 95% CI for the median IKDCs of the DA ACLSR group (n = 23; 75.9) was lower than the prespecified noninferiority margin (n = 21; 86.6). Therefore, the null hypothesis was rejected. However, the upper limit of the 2–sided 95% CI of the DA ACLSR group (100.0) was higher than the median IKDCs of the ACLR group (96.6), rendering the result for noninferiority inconclusive. No statistical difference was found between groups for median IKDCs (repair, 90.2; reconstruction, 96.6). Furthermore, no statistically significant differences were found for any of the secondary outcome measures for the DA ACLSR compared with the ACLR group: KOOS Symptoms, 92.9 versus 96.4; KOOS Pain, 100 versus 97.2; KOOS Activities of Daily Living, 100 versus 100; KOOS Sport and Recreation, 85.0 versus 100; TAS score, 7.0 versus 6.5; VASs, 9.2 versus 8.7; IKDCpe, 81.8% versus 100%; LSIq, ≥91.6 versus ≥88.2; LSIh, ≥95.1 versus ≥90.7; LSIj, ≥94.2 versus ≥97.6; OA grade 0, 90.9% versus 77.8%; clinical ACL failure rate, 20.8% versus 27.2%; and repeat surgery rate, 37.5% versus 20.0%, respectively. Conclusion: It remains inconclusive whether the effectiveness of DA ACLSR is noninferior to that of ACLR in terms of subjective patient–reported outcomes as measured using the IKDCs. Although DA ACLSR may be a viable treatment option for patients with acute ACL rupture, caution must be exercised when considering this treatment for young, active patients, corresponding to the present study population.

Background:Contemporary anterior cruciate ligament (ACL) suture repair techniques have been subject to renewed interest in recent years. Although several clinical studies have yielded good short-term results, high-quality evidence is lacking in regard to the effectiveness of this treatment compared with ACL reconstruction.Hypothesis:Dynamic augmented ACL suture repair is at least as effective as anatomic single-bundle ACL reconstruction for the treatment of acute ACL rupture in terms of patient self-reported outcomes at 2 years postoperatively.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:After stratification and randomization, 48 patients underwent either dynamic augmented ACL suture repair or ACL reconstruction with a single-bundle, all-inside, semitendinosus technique. The International Knee Documentation Committee (IKDC) subjective score at 2 years postoperatively was the primary outcome measure. Patient-reported outcomes (IKDC subjective score, Knee injury and Osteoarthritis Outcome Score, Tegner score, visual analog scale for satisfaction), clinical outcomes (IKDC physical examination score, leg symmetry index for the quadriceps, hamstrings strength, and jump test battery), and radiological outcomes as well as adverse events including reruptures were recorded. Analyses were based on an intention-to-treat principle.Results:The lower limit for the median IKDC subjective score of the repair group (86.2) fell within the prespecified noninferiority margin, confirming noninferiority of dynamic augmented ACL suture repair compared with ACL reconstruction. No statistical difference was found between groups for median IKDC subjective score (repair, 95.4; reconstruction, 94.3). Overall, 2 reruptures (8.7%) occurred in the dynamic ACL suture repair group and 4 reruptures (19.0%) in the ACL reconstruction group; further, 5 repeat surgeries—other than for revision ACL surgery—took place in 4 patients from the dynamic ACL suture repair group (20.8%) and in 3 patients from the ACL reconstruction group (14.3%).Conclusion:Dynamic augmented ACL suture repair is not inferior to ACL reconstruction in terms of subjective patient-reported outcomes as measured with the IKDC subjective score 2 years postoperatively. However, for reasons other than revision ACL surgery due to rerupture, a higher number of related adverse events leading to repeat surgery were seen in the dynamic augmented ACL suture repair group within 2 years postoperatively.Clinical Relevance:Dynamic augmented ACL suture repair might be a viable treatment option for patients with an acute ACL rupture.Registration:NCT02310854 ( ClinicalTrials.gov identifier).

PURPOSE: After revision anterior cruciate ligament reconstruction (ACLR), the rate of return to the pre-injury type of sport (RTS type) is low and graft choice might be an important factor. The aim of this study was to determine whether there is a difference in outcome after revision ACLR using a patellar tendon allograft compared to an ipsilateral patellar tendon autograft. It was hypothesized that the rate of RTS type using an ipsilateral patellar tendon autograft will be superior to using patellar tendon allograft.METHODS: The design is a retrospective cohort study. Inclusion criteria were patients who underwent revision ACLR with a minimum follow-up of 1 year after revision using a patellar allograft or ipsilateral autograft. Primary study parameter was rate of RTS type. Secondary study parameters were RTS level, subscores of the KOOS, the IKDCsubjective, the Tegner score and reasons for no RTS.RESULTS: Eighty-two patients participated in this study (36 allografts and 46 autografts). In patients with a minimum follow-up of 1 year, rate of RTS type was 51.4% for the patellar tendon allograft and 62.8% for the patellar tendon autograft group (n.s.). In patients with a minimum follow-up rate of 2 years, rate of RTS type was 43.3 versus 75.0%, respectively (p = 0.027). No differences in secondary study parameters were found. In patients with a minimum follow-up of 1 year, rate of RTS type was significantly higher (p = 0.025) for patients without anxiety compared to patients who were anxious to perform certain movements.CONCLUSION: After a minimum follow-up of 2 years, rate of RTS type is in favour of using an ipsilateral patellar tendon autograft when compared to using a patellar tendon allograft in patients undergoing revision ACLR; after a minimum follow-up of 1 year, no significant difference was found. In revision ACLR, the results of this study might influence graft choice in favour of autologous graft when the use of an allograft or autograft patellar tendon is considered.LEVEL OF EVIDENCE: III.

Background To assess if during arthroscopic braid-augmented ACL suture repair (ACLSR), the actual positions of the augmentation braids' tunnels corresponded with the positions of their intended and targeted isometric points, and to test the hypothesis that there would be no dispersion in actual positions of the augmentation braids' tunnels compared to their intended and targeted isometric points. Methods In 12 human cadaveric knees, the positions of the augmentation braids' tunnels and their intended and targeted isometric points relative to a femoral and tibial grid were analysed. Furthermore, vector length between these positions was calculated to assess the accuracy and precision of the augmentation braids' tunnel placement. Results There was dispersion for all of the augmentation braids' tunnel positions compared to their intended isometric points. The femoral and tibial vector lengths (mean ± SD (range)) were 2.9 ± 1.0 (1.1–4.1) and 7.1 ± 2.0 (3.2–9.8) mm respectively. Conclusion In augmented ACLSR, with the ruptured ACL in situ, there was dispersion of the positions of the actual small diameter femoral and tibial augmentation braids' tunnels away from their desired isometric points. Clinical relevance The extent of dispersion of the position of both the femoral and tibial tunnels away from their intended isometric positions may cause cyclic length changes with knee motion. An ACLSR with static braid augmentation will thus be vulnerable to cyclic stretching-out. The difficulty of obtaining an isometric tunnel combination for the small diameter augmentation braid may influence the clinician's choice between non-, static or dynamic augmented ACLSR techniques.

Background: There has been renewed interest in the concept of anterior cruciate ligament (ACL) suture repair (ACLSR). Morphologic characteristics of the ruptured ACL remnant play a role in deciding whether a patient is eligible for ACLSR. However, no classification of these characteristics of ACL rupture on magnetic resonance imaging (MRI) scans has yet been compared with intraoperative findings in the context of ACLSR. Purpose: To investigate the value of using preoperative MRI to predict specific characteristics of acute complete ACL rupture. Study Design: Cohort study (diagnostic); Level of evidence, 2. Methods: A total of 25 patients were included. Two radiologists classified ACL rupture location and pattern on preoperative 1.5-T MRI scans with a standard sequence; the results were compared with the corresponding findings at arthroscopy conducted by a single surgeon. The agreement between the MRI and surgical findings was calculated using Cohen κ values. Furthermore, the reliability coefficients of the MRI classifications within and between radiologists were calculated. Results: The agreement between MRI classification and arthroscopic findings for ACL rupture location was slight (Cohen κ, 0.016 [radiologist 1] and 0.087 [radiologist 2]), and for ACL rupture pattern, this was poor to slight (Cohen κ, Conclusion: In the current study, we found poor to slight agreement between MRI classification and arthroscopic findings of specific ACL rupture characteristics. In addition, the intra- and interobserver reliability for MRI classification of the ACL rupture characteristics was slight to moderate.

PURPOSE: There is a lack of objective evidence investigating how previous non-augmented ACL suture repair techniques and contemporary augmentation techniques in ACL suture repair restrain anterior tibial translation (ATT) across the arc of flexion, and after cyclic loading of the knee. The purpose of this work was to test the null hypotheses that there would be no statistically significant difference in ATT after non-, static- and dynamic-augmented ACL suture repair, and they will not restore ATT to normal values across the arc of flexion of the knee after cyclic loading. METHODS: Eleven human cadaveric knees were mounted in a test rig, and knee kinematics from 0° to 90° of flexion were recorded by use of an optical tracking system. Measurements were recorded without load and with 89-N tibial anterior force. The knees were tested in the following states: ACL-intact, ACL-deficient, non-augmented suture repair, static tape augmentation and dynamic augmentation after 10 and 300 loading cycles. RESULTS: Only static tape augmentation and dynamic augmentation restored ATT to values similar to the ACL-intact state directly postoperation, and maintained this after cyclic loading. However, contrary to dynamic augmentation, the ATT after static tape augmentation failed to remain statistically less than for the ACL-deficient state after cyclic loading. Moreover, after cyclic loading, ATT was significantly less with dynamic augmentation when compared to static tape augmentation. CONCLUSION: In contrast to non-augmented ACL suture repair and static tape augmentation, only dynamic augmentation resulted in restoration of ATT values similar to the ACL-intact knee and decreased ATT values when compared to the ACL-deficient knee immediately post-operation and also after cyclic loading, across the arc of flexion, thus allowing the null hypotheses to be rejected. This may assist healing of the ruptured ACL. Therefore, this study would support further clinical evaluation of dynamic augmentation of ACL repair.

Purpose To study the value of tourniquet use during routine arthroscopy of the knee. Methods In this randomized, double-blind controlled trial, 245 patients were included from April 2005 until March 2007 and randomized into an inflated tourniquet group (n = 137) or a deflated tourniquet group (n = 108). The primary outcome was intraoperative visibility. Secondary outcomes were the need to intraoperatively inflate the tourniquet because impaired vision impeded the procedure, the number of times and reason (impaired vision or debris) for flushing the knee, the duration of the procedure (in minutes), and the surgeon's impression of whether the tourniquet was inflated during the procedure. Results Intraoperative visibility was statistically significantly better in the group with the inflated tourniquet. In 11 of the 16 cases in which visibility was rated fair/poor (unsatisfactory), the surgeon felt the need to inflate the tourniquet. In all of the cases the tourniquet had not been previously inflated. In all but 1 case the visibility improved to at least to a rating of good. The frequency of flushing the knee intraoperatively was significantly higher in the deflated tourniquet group. The operative time was not significantly different statistically. Conclusions The results of this study support our hypothesis that routine arthroscopy of the knee with an inflated tourniquet significantly improves visibility, but it does not shorten operative time. Level of Evidence Level I, therapeutic randomized controlled trial.