Anterior cruciate ligament primary repair is a valid treatment option for proximal tears with good to excellent tissue quality in the acute, sub-acute and delayed setting – A letter to the editor

We would like to thank the authors for their recent publication “Arthroscopic biological internal bracing with remnant repair for subacute ACL femoral avulsions”[5Pardiwala D.N. Lee D. Arthroscopic biological internal bracing with remnant repair for subacute ACL femoral avulsions.J ISAKOS. 2023; 8: 54-56Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar]. The authors present a conceptually great technique providing the orthopedic community with an additional alternative approach to treat proximal anterior cruciate ligament (ACL) tears. This technique is performed using a 7 – 8 mm hamstring autograft to provide a biological augmentation to the proximally torn ACL, which is refixated femorally using a suture anchor in the case of a type I tear, or in the presence of a type II tear the autograft is “tunneled” through the stump. We agree that the modern-day treatment algorithm of ACL injuries should be based on a patient-individualized decision process and strongly feel that providers should be able to draw upon the complete, modern-day ACL surgeon’s armamentarium including ACL primary repair (ACLPR), repair with augmentation and reconstruction (ACLR)[8Rilk S. Saithna A. Ferretti A. Sonnery-Cottet B. Kosters C. Bottoni C.R. et al.The modern-day ACL surgeon's armamentarium should include multiple surgical approaches including primary repair, augmentation, and reconstruction: A letter to the Editor.J ISAKOS. 2023; https://doi.org/10.1016/j.jisako.2023.03.434Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar]. The indication for ACLPR or repair with augmentation should be based on the tear type tissue quality and patient age, to name the most critical variables[13Vermeijden H.D. van der List J.P. DiFelice G.S. Arthroscopic Primary Repair of the Anterior Cruciate Ligament With Single-Bundle Graft Augmentation.Arthrosc Tech. 2020; 9: e367-e373Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar]. We also have some constructive criticism of this work, as it seems to us that the literature review that was performed for this work was incomplete and has led to inaccurate statements. First, the authors claim that this technique is unique, however we wish to point out that van der List and DiFelice et al.[10van der List J.P. DiFelice G.S. Preservation of the Anterior Cruciate Ligament: Surgical Techniques.Am J Orthop (Belle Mead NJ). 2016; 45: E406-E414PubMed Google Scholar] published their “preservation first approach” in 2016 which included a repair with augmentation technique that significantly overlaps with the technique presented by Pardiwala and Lee et al.[5Pardiwala D.N. Lee D. Arthroscopic biological internal bracing with remnant repair for subacute ACL femoral avulsions.J ISAKOS. 2023; 8: 54-56Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar]. Following up on this, Gipsman et al. 2018[3Gipsman A.M. Trasolini N. Hatch 3rd, G.F.R. Primary Anterior Cruciate Ligament Single-Bundle Repair With Augmentation for a Partial Anterior Cruciate Ligament Tear.Arthrosc Tech. 2018; 7: e367-e372Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar] published a technical note of their approach, before Vermeijden et al. 2020[13Vermeijden H.D. van der List J.P. DiFelice G.S. Arthroscopic Primary Repair of the Anterior Cruciate Ligament With Single-Bundle Graft Augmentation.Arthrosc Tech. 2020; 9: e367-e373Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar] published an more extensive description of their preceding approach[10van der List J.P. DiFelice G.S. Preservation of the Anterior Cruciate Ligament: Surgical Techniques.Am J Orthop (Belle Mead NJ). 2016; 45: E406-E414PubMed Google Scholar]. An acknowledgement of previously described techniques, and a thorough discussion of the technical distinctions, would serve the reader well to assess innovativeness more accurately and better evaluate clinical applicability. Furthermore, the authors stated that “since ACL repair needs to be performed in the acute phase following injury, it has an increased risk of developing arthrofibrosis”. Our previously updated ACLPR technique is indicated for patients in the acute and chronic setting[7Rilk S. Goodhart G.C. O’Brien R. Vermeijden H.D. van der List J.P. DiFelice G.S. Anatomic Arthroscopic Primary Repair of Proximal Anterior Cruciate Ligament Tears.Arthroscopy Techniques. 2023; https://doi.org/10.1016/j.eats.2023.02.022Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar]. This indication is based on the outcomes of 113 patients treated with ACLPR at a mean of 22.3 ±77.0 weeks (range, 0.6 – 574.0), and 55% of the patients ≤6 weeks following injury, demonstrating low reoperation rates (3%) and no cases of arthrofibrosis[15Vermeijden H.D. Yang X.A. van der List J.P. DiFelice G.S. Role of Age on Success of Arthroscopic Primary Repair of Proximal Anterior Cruciate Ligament Tears.Arthroscopy. 2021; 37: 1194-1201Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar]. In an additional study, comparing ACLPR to ACL reconstruction (ACLR), to assess early range of motion (ROM), again no case presented with arthrofibrosis, and significantly better early ROM was demonstrated for ACLPR[11van der List J.P. DiFelice G.S. Range of motion and complications following primary repair versus reconstruction of the anterior cruciate ligament.Knee. 2017; 24: 798-807Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar]. Multiple authors have recently presented similar results in acute (<4 weeks), sub-acute and/or chronically injured patients[1Ferreira A. Saithna A. Carrozzo A. Guy S. Vieira T.D. Barth J. et al.The Minimal Clinically Important Difference, Patient Acceptable Symptom State, and Clinical Outcomes of Anterior Cruciate Ligament Repair Versus Reconstruction: A Matched-Pair Analysis From the SANTI Study Group.The American Journal of Sports Medicine. 2022; https://doi.org/10.1177/03635465221126171Crossref Scopus (4) Google Scholar, 2Ferretti A. Carrozzo A. Saithna A. Argento G. Annibaldi A. Latini F. et al.Comparison of Primary Repair of the Anterior Cruciate Ligament and Anterolateral Structures to Reconstruction and Lateral Extra-articular Tenodesis at 2-Year Follow-up.Am J Sports Med. 2023; https://doi.org/10.1177/036354652311783013635465231178301Crossref Google Scholar, 9Schneider K.N. Ahlbaumer G. Gosheger G. Theil C. Weller J. Goth A. Promising functional outcomes following anterior cruciate ligament repair with suture augmentation.Knee Surg Sports Traumatol Arthrosc. 2022; https://doi.org/10.1007/s00167-022-07236-4Crossref Scopus (1) Google Scholar, 15Vermeijden H.D. Yang X.A. van der List J.P. DiFelice G.S. Role of Age on Success of Arthroscopic Primary Repair of Proximal Anterior Cruciate Ligament Tears.Arthroscopy. 2021; 37: 1194-1201Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar]. In addition, a recent meta-analysis pointed out that early ACLR using modern-day approaches, is not correlated with an increased risk of arthrofibrosis, disproving historical outcomes[14Vermeijden H.D. Yang X.A. Rademakers M.V. Kerkhoffs G. van der List J.P. DiFelice G.S. Early and Delayed Surgery for Isolated ACL and Multiligamentous Knee Injuries Have Equivalent Results: A Systematic Review and Meta-analysis.Am J Sports Med. 2022; 10 (1177/036354652110693563635465211069356)Google Scholar]. Finally, the authors claim that ACL repair cannot be performed in the subacute setting and therefore indicate ACL augmentation. However, an analysis specifically comparing patients undergoing acute (≤3 weeks) versus delayed ACLPR (>3 months) at a minimum of 2-year follow-up, showed no significant difference in failure rates (p > 0.999), and no cases of arthrofibrosis in either group[12Vermeijden H.D. van der List J.P. DiFelice G.S. Acute and delayed anterior cruciate ligament repair results in similar short to mid-term outcomes.Knee. 2021; 29: 142-149Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar], indicating that ACL repair is a valid treatment option when a proximal tear with good tissue quality is present, regardless of timing. We agree with the authors that ACL augmentation using autografts has its valid indications. However, we recommend to not base this on timing. Delaying surgery can decrease likelihood of good tissue quality[4Magarian E.M. Fleming B.C. Harrison S.L. Mastrangelo A.N. Badger G.J. Murray M.M. Delay of 2 or 6 weeks adversely affects the functional outcome of augmented primary repair of the porcine anterior cruciate ligament.Am J Sports Med. 2010; 38: 2528-2534Crossref PubMed Scopus (46) Google Scholar] and even potentially increase the risk of meniscus and/or chondral damage[6Petersen W. Guenther D. Imhoff A.B. Herbort M. Stein T. Schoepp C. et al.Management after acute rupture of the anterior cruciate ligament (ACL). Part 1: ACL reconstruction has a protective effect on secondary meniscus and cartilage lesions.Knee Surg Sports Traumatol Arthrosc. 2023; 31: 1665-1674Crossref PubMed Scopus (2) Google Scholar], but the possibility of repair should be based on tear location and tissue quality instead. Once again, we wish to thank the authors for their valuable contribution and voice our agreement of the importance of ligament preservation procedures when treating ACL injuries. However, we believe that ACLPR does not need to be limited to the acute setting. In addition, ACLPR performed for proximal tears with good to excellent tissue quality, has not been shown to be correlated with an increased risk of arthrofibrosis when treated acutely, and survival rates show equal results for acute and delayed interventions. It is important for readers to appreciate the overall literature on ACL healing and ACL repair, even in the case of a surgical technique study. G.S.D. is on the speakers bureau of Arthrex. ☒ The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Gregory S. DiFelice reports a relationship with Arthrex Inc that includes: on the speakers bureau.