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Commentary and Perspective

The Role of ACL Repair in Modern Times

Commentary on an article by Anne N. Sporsheim, MD, et al.: “Autologous BPTB ACL Reconstruction Results in Lower Failure Rates Than ACL Repair with and without Synthetic Augmentation at 30 Years of Follow-up. A Prospective Randomized Study”

Tao, Matthew A. MD

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The Journal of Bone and Joint Surgery: December 4, 2019 - Volume 101 - Issue 23 - p e129
doi: 10.2106/JBJS.19.01099
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Commentary

Rare is the study in orthopaedics in which a well-done randomized trial involves long-term follow-up on a topic that remains clinically relevant. However, the work by Sporsheim et al. provides 30-year data on surgically treated anterior cruciate ligament (ACL) tears, which remain an incredibly common injury in sports medicine. Awareness of ACL tears seems to be ever increasing in the public eye as high-profile athletes suffer these injuries each year with notable fanfare in the national media. As such, interest in the ACL by both surgeons and patients alike is particularly high as we live in a return-to-play world.

Over the years, many techniques have been evaluated as to the best way to treat ACL injuries, and this remains a topic in evolution. Primary repair was quite popular several decades ago but eventually fell out of favor because some of the preliminary results from this cohort as well as others demonstrated unacceptably high failure rates1. However, there has been a resurgence of interest in repair, as opposed to reconstruction, in recent years as surgeons investigate better ways to recreate stability, restore function, and reduce reinjury rates going forward.

It is worth acknowledging that the general technique surrounding the care of ACL tears—operative timing, arthroscopic versus open, cast application, and extended periods of non-weight-bearing—have evolved a great deal since the 1980s, and these changes have largely been driven by data demonstrating improved outcomes. Even so, the study by Sporsheim et al. provides a methodologically solid evaluation with 30-year follow-up on a topic that remains of eminent interest. Bone-patellar tendon-bone (BPTB) continues to be a common autograft of choice for ACL reconstructions, and both primary repair and repair with suture augmentation are once again common approaches. The most notable finding in this study was a significantly increased revision rate for both the primary repair group and the group that had the synthetic ligament augmentation device compared with the BPTB group. However, no difference was found with respect to laxity, patient-reported outcomes, radiographic signs of osteoarthritis, or conversion to arthroplasty.

The resurrection of ACL repair seems born out of the fact that, despite overall high failure rates, a subset of patients did quite well1,2. Recent work in the Bridge-Enhanced ACL Repair (BEAR) trials has provided encouraging results utilizing a biologically based repair with additional suture augmentation compared with reconstruction3. However, other data have suggested a concerningly high failure rate when repair with suture ligament augmentation was used4. Thus, the “when, where, and how” of ACL repair in modern times has yet to be fully elucidated, and as such, it should be approached cautiously and scientifically.

Ultimately, our goal as surgeons is one of continual improvement—not only in sophistication of technique but even more so in improved outcomes. I applaud the current efforts of those reinvestigating the role for ACL repair, and as a community, we look forward to the data in coming years. However, the long-term results presented by Sporsheim et al. are compelling and should provide some pause. Their data serve as a call to scientific rigor, and to a degree, the burden of proof is on research going forward to demonstrate clear efficacy of repair, with or without augmentation, in light of historical failures. If we are indeed able to clearly define a better population, technique, and protocol, then success is attainable, and our patients stand to benefit.

References

1. Taylor SA, Khair MM, Roberts TR, DiFelice GS. Primary repair of the anterior cruciate ligament: a systematic review. Arthroscopy. 2015 Nov;31(11):2233-47. Epub 2015 Jul 10.
2. van der List JP, Vermeijden HD, Sierevelt IN, DiFelice GS, van Noort A, Kerkhoffs GMMJ. Arthroscopic primary repair of proximal anterior cruciate ligament tears seems safe but higher level of evidence is needed: a systematic review and meta-analysis of recent literature. Knee Surg Sports Traumatol Arthrosc. 2019 Sep 5:1-12. Epub 2019 Sep 5.
3. Murray MM, Kalish LA, Fleming BC, Flutie B, Freiberger C, Henderson RN, Perrone GS, Thurber LG, Proffen BL, Ecklund K, Kramer DE, Yen YM, Micheli LJ; BEAR Trial Team. Bridge-enhanced anterior cruciate ligament repair: two-year results of a first-in-human study. Orthop J Sports Med. 2019 Mar 22;7(3):2325967118824356.
4. Gagliardi AG, Carry PM, Parikh HB, Traver JL, Howell DR, Albright JC. ACL repair with suture ligament augmentation is associated with a high failure rate among adolescent patients. Am J Sports Med. 2019 Mar;47(3):560-6. Epub 2019 Feb 7.

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