Vermeijden Harmen D, van der List Jelle P, DiFelice Gregory S
Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA.
Department of Orthopaedic Surgery, Spaarne Gasthuis Hospital, Hoofddorp, the Netherlands.
Video J Sports Med. 2021 May 4;1(3):26350254211005461. doi: 10.1177/26350254211005461. eCollection 2021 May-Jun.
Historically, the midterm outcomes of open anterior cruciate ligament (ACL) repair were rather disappointing, and ACL reconstruction subsequently became the surgical standard for ACL injuries. Recent studies, however, have shown that there might be a role for arthroscopic primary repair in appropriately selected patients with proximal ACL tears.
Due to more prominent blood supply in the proximal ligament region, ACL repair should only be performed in patients with proximal tears and good-to-excellent tissue quality. Although all patients are potential candidates, this procedure is preferably performed acutely and in adult patients.
First, it is identified whether a proximal tear with good tissue quality is present. Then, both ACL bundles are sutured individually from distal to proximal using a Bunnell-type pattern and a self-retrieving suture passer. The posterolateral bundle is then reattached first in anatomical fashion, using a 4.75-mm vented biocomposite suture anchor. Next, the suture anchor of the anteromedial bundle is preloaded with an internal suture tape augmentation. After anchor deployment, the suture tape augmentation is channeled through a small 2.5-mm tibial tunnel in the anterior third of the tibial ACL footprint. Finally, the suture augmentation is tensioned near full extension and fixed to the tibia's anteromedial cortex using single suture anchor fixation.
Recently, we have published a series of the first 113 consecutive repair patients with minimum 2-year follow-up, of which 60 received additional suture augmentation. In this cohort, the overall failure rate was 13%, which was similar to 3 other studies on modern-day ACL repair (range: 5%-15%). Subgroup analysis showed that the failure rate was much higher in patients ≤21 years (38%) but low in patients >21 years (0%). Finally, it has been shown that there is an earlier return of knee motion, complications are rare, and there is less joint awareness after ACL repair as compared with ACL reconstruction.
Selective, modern-day, arthroscopic primary ACL repair with suture augmentation seems to be a good alternative to ACL reconstruction in carefully selected patients, which include patients with proximal tears and good tissue quality and aged ≥22 years.
从历史上看，开放性前交叉韧带（ACL）修复的中期结果相当令人失望，随后ACL重建成为ACL损伤的手术标准。然而，最近的研究表明，对于适当选择的近端ACL撕裂患者，关节镜下一期修复可能会发挥作用。
由于近端韧带区域的血供更为丰富，ACL修复仅应在近端撕裂且组织质量良好至优秀的患者中进行。虽然所有患者都是潜在的候选者，但该手术最好在急性期对成年患者进行。
首先，确定是否存在组织质量良好的近端撕裂。然后，使用Bunnell型缝合法和自回收缝线推送器从远端到近端分别缝合ACL的两个束。然后，使用4.75毫米带孔生物复合材料缝线锚钉以解剖方式首先重新附着后外侧束。接下来，在内侧前束的缝线锚钉上预加载内部缝线带增强装置。在锚钉植入后，将缝线带增强装置穿过胫骨ACL足迹前三分之一处的一个2.5毫米小胫骨隧道。最后，在接近完全伸展时拉紧缝线增强装置，并使用单个缝线锚钉固定将其固定在胫骨的内侧前皮质上。
最近，我们发表了一系列对首批113例连续接受修复的患者进行至少2年随访的研究，其中60例接受了额外的缝线增强。在这个队列中，总体失败率为13%，这与其他3项关于现代ACL修复的研究相似（范围：5%-15%）。亚组分析表明，≤21岁患者的失败率要高得多（38%），而>21岁患者的失败率较低（0%）。最后，研究表明，与ACL重建相比，ACL修复后膝关节活动恢复更早，并发症罕见，关节感觉也更少。
对于精心挑选的患者，包括近端撕裂、组织质量良好且年龄≥22岁的患者，选择性的现代关节镜下一期ACL修复并辅以缝线增强似乎是ACL重建的一个良好替代方案。
