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Clinical evaluation and management of anterior cruciate ligament (ACL) injury is one of the most widely researched topics in orthopedic sports medicine, giving providers ample data on which to base their practices. The ACL is also the most commonly treated knee ligament. This study reports on current topics and research in clinical management of ACL injury, starting with evaluation, operative versus nonoperative management, and considerations in unique populations. Discussion of graft selection and associated procedures follows. Areas of uncertainty, rehabilitation, and prevention are the final topics before a reflection on the current state of ACL research and clinical management of ACL injury. Level of evidence V.

A trend within the orthopedic community is rejection of the belief that “one size fits all.” Freddie Fu, among others, strived to individualize the treatment of anterior cruciate ligament (ACL) injuries based on the patient’s anatomy. Further, during the last two decades, greater emphasis has been placed on improving the outcomes of ACL reconstruction (ACL-R). Accordingly, anatomic tunnel placement is paramount in preventing graft impingement and restoring knee kinematics. Additionally, identification and management of concomitant knee injuries help to re-establish knee kinematics and prevent lower outcomes and registry studies continue to determine which graft yields the best outcomes. The utilization of registry studies has provided several large-scale epidemiologic studies that have bolstered outcomes data, such as avoiding allografts in pediatric populations and incorporating extra-articular stabilizing procedures in younger athletes to prevent re-rupture. In describing the anatomic and biomechanical understanding of the ACL and the resulting improvements in terms of surgical reconstruction, the purpose of this article is to illustrate how basic science advancements have directly led to improvements in clinical outcomes for ACL-injured patients. Level of evidence V.

Purpose Selective anteromedial or posterolateral bundle reconstruction is recognized as a treatment modality in partial anterior cruciate ligament (ACL) reconstruction (ACLR) with a biomechanically sufficient ACL remnant. However, there is paucity in literature investigating clinical outcomes of standard ACLR with preservation of residual continuous but biomechanically insufficient ACL tissue. The aim of this study was to investigate the influence of preservation of residual continuous but biomechanical insufficient ACL tissue in standard ACLR on complication and repeat surgery rate, and patient reported and clinical outcome. Methods The retrospective cohort comprised 134 patients (age 23 ± 7 years; Tegner 6 ± 3) with an isolated acute ACL tear. In 67 patients, residual continuous but biomechanically insufficient ACL tissue was present and preserved based on visual inspection, probing of the ACL tissue and Lachman test under arthroscopic view (standard reconstruction with tissue preservation; SRTP). These patients were matched to 67 patients that underwent ACLR where no residual ACL tissue could be preserved (standard reconstruction; SR) based on gender, age and chondral and/or meniscal status. Clinical failure (recurrent instability, pathological ACL graft laxity and/or ACL graft discontinuity), other complication and repeat-surgery rate within index surgery and 1-year and within index surgery and 2-year follow-up, and patient reported and clinical outcomes at 1-year and at 2-year follow-up were compared. Results A statistically significant lower clinical failure rate within index surgery and 1-year (SRTP, 3%; SR, 13%; P  = 0.028) and within index surgery and 2-year follow-up (SRTP, 3%; SR, 23%; P  = 0.001), and revision ACL surgery rate within index surgery and 1-year (SRTP, 2%; ST, 10%; P  = 0.029) and within index surgery and 2-year follow-up (SRTP, 2%; SR, 18%; P  = 0.001) was found in the SRTP group. No statistically significant differences were found for other investigated outcomes in patients that were without clinical failure. Conclusion This study shows that in ACLR surgery, preservation of residual continuous but biomechanical insufficient ACL tissue might lead to lower clinical failure rate and ACL revision surgery rate within index surgery and 1-year, and within index surgery and 2-year follow-up compared to standard ACLR where no residual continuous ACL tissue could be preserved. Level of evidence III.

Background: Bridge-enhanced anterior cruciate ligament repair (BEAR) combines suture repair of the anterior cruciate ligament (ACL) with a specific extracellular matrix scaffold (the BEAR scaffold) that is placed in the gap between the torn ends of the ACL to facilitate ligament healing. Purpose/Hypothesis: The purpose of this study was to report the 12- and 24-month outcomes of patients who underwent the BEAR procedure compared with a nonrandomized concurrent control group who underwent ACL reconstruction (ACLR) with an autograft. We hypothesized that the BEAR group would have physical examination findings, patient-reported outcomes, and adverse events that were similar to those of the ACLR group. Study Design: Cohort study; Level of evidence, 2. Methods: Ten patients underwent BEAR, and 10 underwent ACLR with a 4-stranded hamstring autograft. At 24 months, 9 of the 10 BEAR patients and 7 of the 10 ACLR patients completed a study visit. Outcomes reported included International Knee Documentation Committee (IKDC) subjective and objective results, knee anteroposterior (AP) laxity findings via an arthrometer, and functional outcomes. Results: There were no graft or repair failures in the first 24 months after surgery. The IKDC subjective scores in both groups improved significantly from baseline (P < .0001) at 12 and 24 months, to 84.6 ± 17.2 in the ACLR group and to 91.7 ± 11.7 in the BEAR group. An IKDC objective grade of A (normal) was found in 44% of patients in the BEAR group and in 29% of patients in the ACLR group at 24 months; no patients in either group had C (abnormal) or D (severely abnormal) grades. Arthrometer testing demonstrated mean side-to-side differences in AP laxity that were similar in the 2 groups at 24 months (BEAR, 1.94 ± 2.08 mm; ACLR, 3.14 ± 2.66 mm). Functional hop testing results were similar in the 2 groups at 12 and 24 months after surgery. Hamstring strength indices were significantly higher in the BEAR group compared with the ACLR group (P = .0001). Conclusion: In this small, first-in-human study, BEAR produced similar outcomes to ACLR with a hamstring autograft. BEAR may result in knee stability and patient-reported outcomes at 2 years sufficient to warrant longer term studies of efficacy in larger groups of patients.

Introduction : Anterior cruciate ligament (ACL) tear is one of the most frequent ligamentous injuries. The gold standard for ACL tears is autograft reconstruction. However, ACL repair has regained enthusiasm with more recent results showing comparable outcomes to its reconstructive counterpart. Methods : PubMed, Cochrane, and Google Scholar (pp. 1–20) were searched until November 2022. The clinical outcomes consisted of the International Knee Documentation Committee (IKDC) score, Knee Injury and Osteoarthritis Outcome Score (KOOS), the side-to-side difference in Anteroposterior (AP) knee laxity, the forces of the hamstring, quadriceps, and hip abduction as well as hopping tests. Results : Only two studies were included in this meta-analysis. ACL repair was shown to have better Hamstrings strength. The rest of the analyzed outcomes were comparable. Discussion : This is the first meta-analysis comparing these two treatments. The ACL repair showed no differences in muscle strength (quadriceps and hip abductors), postoperative knee scores, and knee joint laxity when compared to ACL reconstruction. However, it showed better hamstring strength. Further randomized clinical studies will be needed to compare both of these techniques.

Background: The preservation of the anterior cruciate ligament (ACL) remnant during reconstruction or repair could offer advantages such as enhanced vascularity, proprioception, and biomechanical properties. However, research on the clinical factors influencing ACL remnant preservation at the time of surgery is limited. Purpose/Hypothesis: The purpose was to identify clinical factors influencing the amount of ACL remnant during surgery. It was hypothesized that not solely the delay from injury to surgery influences the amount of ACL remnant present at the time of surgery, but also other patient characteristics such as sex and age, as well as intraoperative findings. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective analysis of prospectively collected data was performed on patients who underwent arthroscopic ACL reconstruction between January 2013 and December 2022. ACL remnants were categorized based on their location into tibial attachment, midsubstance, and femoral attachment, accounting for 20%, 60%, and 20% of the total ACL length, respectively. A multivariate logistic regression was performed to identify factors predictive of the amount of ACL remnant. Results: In a cohort of 5725 patients, different variables were associated with an ACL remnant <20% at the time of surgery. Patients aged ≤20 years had an odds ratio of 1.748 (95% CI, 1.473-2.075; P < .0001), and those aged between 20 and 30 years had an odds ratio of 1.440 compared with those aged >30 years. Female patients had an odds ratio of 1.253 (95% CI, 1.087-1.446; P = .0019). A surgical delay >12 months was associated with an odds ratio of 3.134 (95% CI, 2.640-3.720; P < 0001). The presence of meniscal and chondral lesions had odds ratios of 1.784 (95% CI, 1.570-2.028; P < .0001) and 1.761 (95% CI, 1.426-2.171; P < .0001), respectively. Conclusion: Increased age at surgery was positively associated with a remnant size ≥20% of the ACL. Female sex, longer delay between accident and surgery, and associated injuries of intra-articular structures were risk factors for a remnant size <20%.

Purpose It was the aim to assess all published original research dealing with dynamic repair of the anterior cruciate ligament (ACL) and to provide a semi-quantitative analysis of clinical outcome reports. Methods Both OVIS and MEDLINE databases were utilized for allocation of articles. All preclinical and clinical studies related to dynamic intraligamentary stabilization (DIS) were identified. Results were tabulated and semi-quantitative analysis performed. Results Twenty-three articles related to DIS were identified. The predominant level of evidence ranged between II and IV, with only one level I study. Reported failure rates ranged between 4% and 13.6%. Most clinical studies only reported revision rates without referring to failure of restoring stability. Highest success was achieved with proximal ACL ruptures. Both the level of physical activity and  patient age have been found to influence the risk of failure. Conclusion There is sufficient evidence to support that DIS repair may be an effective modality for the treatment of acute proximal tears of the ACL. However, comparative studies are lacking. Upcoming studies should compare the technique to ACL reconstruction with failure as an endpoint. Comparison to rigid methods of proximal fixation is also necessary to justify the need for dynamic fixation. Overall, there is evidence to suggest the potential space for ACL repair in the decision tree for individualized treatment planning. The best outcome will be in the hands of the best patient selectors. Level of evidence IV.

Background: Anterior cruciate ligament (ACL) injuries are common among active patients and can be managed with primary repair or reconstruction. The most important predictor of good outcomes after primary repair is a more proximal tear location. Preoperative magnetic resonance imaging (MRI) guides surgical decision making, but the accuracy of MRI in identifying tear location is understudied. Purpose: To evaluate the accuracy of preoperative MRI in identifying ACL tear location. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Patients who underwent ACL reconstruction or repair by 2 surgeons at a single, urban academic medical center between 2019 and 2024 were collected. Exclusion criteria included previous ACL surgery and inadequate preoperative or intraoperative imaging. The location of the ACL tear on preoperative MRI scan was retrospectively graded using the modified Sherman classification in a blinded manner. Reference diagnosis was the tear location as noted in the surgeon’s operative note and confirmed with arthroscopic images. The primary endpoint was the accuracy of MRI for predicting intraoperative tear type. Results: A total of 203 patients were included in this study. MRI accurately predicted the ACL tear type seen arthroscopically only 35.5% (72/203) of the time. When MRI did not match the arthroscopic diagnosis, the MRI was within 1 classification grade 74.8% (98/131) of the time. Of the incorrect gradings, 71.0% (93/131) were overclassifications (MRI tear classification more distal than found during arthroscopy). MRI was more sensitive in detecting proximal third (type II) and midsubstance (type III) tears (43.7% and 51.6%, respectively) than it was for detecting proximal avulsion (type I) tears (2.5%). Conclusion: MRI was unreliable for determining the precise location of an ACL tear. MRI tended to overestimate how distal a tear was compared with arthroscopic findings, which may influence patient counseling, preoperative planning, and surgical decision making.

Purpose An enhanced understanding of anterior cruciate ligament (ACL) healing and advancements in arthroscopic instrumentation has resulted in a renewed interest in ACL repair. Augmentation of a ligament repair with suture tape reinforces the ligament and acts as a secondary stabilizer. This study assesses the 5-year patient-reported outcomes of primary repair with suture tape augmentation for proximal ACL tears. Methods Thirty-seven consecutive patients undergoing ACL repair with suture tape augmentation for an acute proximal rupture were prospectively followed up for a minimum of 5 years. Patients with midsubstance and distal ruptures, poor ACL tissue quality, retracted ACL remnants and multiligament injuries were excluded. Patient-reported outcome measures were collated using the Knee Injury and Osteoarthritis Outcomes Score (KOOS), Visual Analogue Pain Scale (VAS-pain), Veterans RAND 12-Item Health Survey (VR-12) and the Marx Activity Scale. Patients with a re-rupture were identified. Results Three patients were lost to follow-up leaving 34 patients in the final analysis (91.9%). The mean KOOS at 5 years was 88.5 (SD 13.8) which improved significantly from 48.7 (SD 18.3) preoperatively ( p  < 0.01). The VAS score improved from 2.3 (SD 1.7) to 1.0 (SD 1.5) and the VR-12 score improved from 35.9 (SD 10.3) to 52.4 (SD 5.9) at 5 years ( p  < 0.01). However, the Marx activity scale decreased from 12.4 (SD 3.4) pre-injury to 7.3 (SD 5.2) at 5 years ( p  = 0.02). Six patients had a re-rupture (17.6%) and have since undergone a conventional ACL reconstruction for their revision surgery with no issues since then. These patients were found to be younger and have higher initial Marx activity scores than the rest of the cohort ( p  < 0.05). Conclusion Primary repair with suture tape augmentation for proximal ACL tears demonstrates satisfactory outcomes in 28 patients (82.4%) at 5-year follow-up. Six patients sustained a re-rupture and have no ongoing problems following treatment with a conventional ACL reconstruction. These patients were significantly younger and had higher initial Marx activity scores. Level of evidence Level IV.

Background: This study assessed the safety of the newly developed bridge-enhanced anterior cruciate ligament (ACL) repair (BEAR), which involves suture repair of the ligament combined with a bioactive scaffold to bridge the gap between the torn ligament ends. As the intra-articular environment is complex in its response to implanted materials, this study was designed to determine whether there would be a significant rate of adverse reaction to the implanted scaffold. Hypothesis: The primary hypothesis was that the implanted scaffold would not result in a deep joint infection (arthrocentesis with positive culture) or significant inflammation (clinical symptoms justifying arthrocentesis but negative culture). The secondary hypotheses were that patients treated with BEAR would have early postoperative outcomes that were similar to patients treated with ACL reconstruction with an autologous hamstring graft. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 20 patients were enrolled in this nonrandomized, first-in-human study. Ten patients received BEAR treatment and 10 received a hamstring autograft ACL reconstruction. The BEAR procedure was performed by augmenting a suture repair with a proprietary scaffold, the BEAR scaffold, placed in between the torn ends of the ACL at the time of suture repair. The BEAR scaffold is to our knowledge the only device that fills the gap between the torn ligament ends to have current Investigational Device Exemption approval from the Food and Drug Administration. Ten milliliters of autologous whole blood were added to the scaffold prior to wound closure. Outcomes were assessed at 3 months postoperatively. The outcomes measures included postoperative pain, muscle atrophy, loss of joint range of motion, and implant failure (designated by an International Knee Documentation Committee grade C or D Lachman test and/or an absence of continuous ACL tissue on magnetic resonance images). Results: There were no joint infections or signs of significant inflammation in either group. There were no differences between groups in effusion or pain, and no failures by Lachman examination criteria (BEAR, 8 grade A and 2 grade B; ACL reconstruction, 10 grade A). Magnetic resonance images from all of the BEAR and ACL-reconstructed patients demonstrated a continuous ACL or intact graft. In addition, hamstring strength at 3 months was significantly better in the BEAR group than in the hamstring autograft group (mean ± SD: 77.9% ± 14.6% vs 55.9% ± 7.8% of the contralateral side; P < .001). Conclusion: The results of this study suggest that the BEAR procedure may have a rate of adverse reactions low enough to warrant a study of efficacy in a larger group of patients.