van der List Jelle P, DiFelice Gregory S
Orthopaedic Sports Medicine and Shoulder Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, United States.
Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, United States.
Surgeon. 2017 Jun;15(3):161-168. doi: 10.1016/j.surge.2016.09.006. Epub 2016 Oct 6.
Over the last century, many surgical treatments have been developed in the orthopedic field, including treatments of anterior cruciate ligament (ACL) injuries. These treatments ideally evolve in a process of trial and error with prospective comparison of new treatments to the current treatment standard. However, these evolutions are sometimes not linear and periodically undergo paradigm shifts. In this article, we review the evolution of ACL treatment and explain how it underwent a paradigm shift. Open primary ACL repair was the most common treatment in the 1970s and 1980s, but because multiple studies noted deterioration of outcomes at mid-term follow-up, in addition to several randomized clinical trials (RCTs) that noted better outcomes following ACL reconstruction, the open primary repair technique was abandoned. At the end of the primary repair era, however, several studies showed that outcomes of open primary repair were good to excellent and did not deteriorate when this technique was selectively performed in patients with proximal ACL tears, whereas primary repair led to disappointing and unpredictable results in patients with mid-substance tears. Unfortunately, enrollment of patients in the aforementioned RCTs was already finished, ultimately leading to abandoning of open primary repair, despite the advantages of ligament preservation. In this review, we discuss (I) why the evolution of ACL treatment underwent a paradigm shift, (II) which factors may have played a role in this and (III) what the future role of arthroscopic primary ACL repair is in the evolution of ACL treatments.
在过去的一个世纪里，骨科领域开发了许多外科治疗方法，包括前交叉韧带（ACL）损伤的治疗。理想情况下，这些治疗方法是在反复试验的过程中发展起来的，即将新治疗方法与当前的治疗标准进行前瞻性比较。然而，这些发展有时并非线性的，并且会周期性地经历范式转变。在本文中，我们回顾了ACL治疗的发展历程，并解释了它是如何经历范式转变的。开放一期ACL修复在20世纪70年代和80年代是最常见的治疗方法，但由于多项研究指出中期随访时结果恶化，此外还有几项随机临床试验（RCT）表明ACL重建后的结果更好，因此开放一期修复技术被摒弃。然而，在一期修复时代末期，几项研究表明，对于近端ACL撕裂患者选择性地采用开放一期修复技术时，其结果良好至优秀，且不会恶化，而对于韧带中部撕裂的患者，一期修复则导致令人失望且不可预测的结果。不幸的是，上述RCT的患者招募已经完成，最终导致开放一期修复被放弃，尽管其具有保留韧带的优势。在本综述中，我们讨论了（I）ACL治疗的发展为何会经历范式转变，（II）哪些因素可能在其中发挥了作用，以及（III）关节镜下一期ACL修复在ACL治疗发展中的未来作用是什么。
