Arthroscopic Primary Repair of Proximal Anterior Cruciate Ligament Tears: With or Without Additional Suture Augmentation?

OBJECTIVES: Over the last years, arthroscopic primary repair of anterior cruciate ligament (ACL) tears has shown excellent results owing to appropriate patient selection (only repairing proximal ACL tears and good tissue quality), minimal invasive surgery (arthroscopy) and focus on early range of motion. Some surgeons have repaired proximal ACL tears without suture augmentation while others have used internal suture augmentation to reinforce and thus protect the repaired ligament during range of motion. No studies have yet compared the two surgical techniques. The objective of this study was to compare failure rates, reoperation rates and patient-reported outcomes of arthroscopic primary repair with versus without suture augmentation. METHODS: A retrospective search for all patients treated with suture anchor arthroscopic primary ACL repair between April 2008 and June 2016 was performed. All patients with isolated proximal ACL tears (type I) were included. Since the development of internal suture augmentation, this reinforcement was added to the repaired ACLs. Minimum follow-up length was 1.0 years. RESULTS: A total of 56 patients were included (mean age 33 years (range: 14 - 57), 59% male) of which 28 (50%) patients received additional suture augmentation. Mean follow-up was 2.3 years (range: 1.0-9.2). Six of all patients had reruptured their repaired ACL (10.7%), of which four underwent uncomplicated ACL reconstruction and two were treated conservatively. Four reruptures were initially treated with primary repair only (4/28, 14.3%) and two patients with additional suture augmentation (2/28, 7.1%; p = 0.431). During follow-up, three patients underwent reoperation (5.4%; two for medial meniscus tear (one in each group) and one for tibial suture anchor removal of the suture augmentation). Patient-reported outcomes have so far been collected in 20 patients without reruptures (currently collecting), with mean Lysholm score of 96, modified Cincinnati 94, SANE 93, pre-injury Tegner 6.7, postoperative Tegner 6.3 and subjective IKDC 91. Objective IKDC was A in 90%, B in 5%, C in 5%. CONCLUSION: In this study, the total failure rate of arthroscopic primary ACL repair was 10.7% and was lower with additional suture augmentation (7.1%) than primary repair alone (14.3%). Patients with failed ACL repair underwent uncomplicated primary ACL reconstruction. We recommend adding suture augmentation in high-risk patients (i.e. adolescents, ones with hyperlaxity, high contact sports), to protect the repaired ligament, especially during early range of motion. These data support treating type I proximal ACL tears with arthroscopic primary repair.