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Review
. 2024 Jun 11;12(6):23259671241253591.
doi: 10.1177/23259671241253591. eCollection 2024 Jun.

Clinical Results of Primary Repair Versus Reconstruction of the Anterior Cruciate Ligament: A Systematic Review and Meta-analysis of Contemporary Trials

Kyle N Kunze  1   2 , Ayoosh Pareek  1   2 , Benedict U Nwachukwu  1   2 , Anil S Ranawat  1   2 , Andrew D Pearle  1   2 , Bryan T Kelly  1   2 , Answorth A Allen  1   2 , Riley J Williams 3rd  1   2
Affiliations
Review

Clinical Results of Primary Repair Versus Reconstruction of the Anterior Cruciate Ligament: A Systematic Review and Meta-analysis of Contemporary Trials

Kyle N Kunze et al. Orthop J Sports Med. .

Abstract

Background: Primary anterior cruciate ligament (ACL) repair has gained renewed interest in select centers for patients with proximal or midsubstance ACL tears. Therefore, it is important to reassess contemporary clinical outcomes of ACL repair to determine whether a clinical benefit exists over the gold standard of ACL reconstruction (ACLR).

Purpose: To (1) perform a meta-analysis of comparative trials to determine whether differences in clinical outcomes and adverse events exist between ACL repair versus ACLR and (2) synthesize the midterm outcomes of available trials.

Study design: Systematic review; Level of evidence, 3.

Methods: The PubMed, OVID/Medline, and Cochrane databases were queried in August 2023 for prospective and retrospective clinical trials comparing ACL repair and ACLR. Data pertaining to tear location, surgical technique, adverse events, and clinical outcome measures were recorded. DerSimonian-Laird random-effects models were constructed to quantitatively evaluate the association between ACL repair/ACLR, adverse events, and clinical outcomes. A subanalysis of minimum 5-year outcomes was performed.

Results: Twelve studies (893 patients; 464 ACLR and 429 ACL repair) were included. Random-effects models demonstrated a higher relative risk (RR) of recurrent instability/clinical failure (RR = 1.64; 95% confidence interval [CI], 1.04-2.57; P = .032), revision ACLR (RR = 1.63; 95% CI, 1.03-2.59; P = .039), and hardware removal (RR = 4.94; 95% CI, 2.10-11.61; P = .0003) in patients who underwent primary ACL repair versus ACLR. The RR of reoperations and complications (knee-related) were not significantly different between groups. No significant differences were observed when comparing patient-reported outcome scores. In studies with minimum 5-year outcomes, no significant differences in adverse events or Lysholm scores were observed.

Conclusion: In contemporary comparative trials of ACL repair versus ACLR, the RR of clinical failure, revision surgery due to ACL rerupture, and hardware removal was greater for primary ACL repair compared with ACLR. There were no observed differences in patient-reported outcome scores, reoperations, or knee-related complications between approaches. In the limited literature reporting on minimum 5-year outcomes, significant differences in adverse events or the International Knee Documentation Committee score were not observed.

Keywords: adverse events; anterior cruciate ligament; patient-reported outcomes; reconstruction; repair.

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Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: A.P. has received education payments from Smith+Nephew and hospitality payments from Medical Device Business Services. B.U.N. has received grant support from Arthrex, education payments from Arthrex and Smith+Nephew, consulting fees from Stryker, and hospitality payments from Medical Device Business Services and Zimmer Biomet. A.S.R. has received education payments from Gotham Surgical; consulting fees from Anika Therapeutics, Bodycad, Smith+Nephew, Xiros, Stryker, Flexion Therapeutics, Arthrex, and Heron Therapeutics; and nonconsulting fees from Arthrex and Smith+Nephew. A.S.P. has received consulting fees from Smith+ Nephew, Zimmer Biomet, DePuy Synthes, Exactech, and Stryker; nonconsulting fees from Smith+Nephew; royalties from Smith+Nephew and Zimmer Biomet; and has stock/stock options in Smith+Nephew. B.T.K. has received education payments from Arthrex; consulting fees from Arthrex; nonconsulting fees from Arthrex and Synthes; royalties from Arthrex; and hospitality payments from Stryker and Smith+Nephew. R.J.W. has received royalty or license from Arthrex; consulting fees and nonconsulting fees from Arthrex; and has stock/stock options in Smith+Nephew. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Figures

Figure 1.
Figure 1.
Flowchart for study search and inclusion.
Figure 2.
Figure 2.
Cochrane Risk-of-Bias Version 2 tool assessment for the included randomized controlled trials. (A) Traffic light plot of specific bias domains. (B) Summary plot demonstrating overall percentage of bias within studies.
Figure 3.
Figure 3.
Forest plot depicting random-effects model for RR for clinical failure after ACLR after primary repair versus reconstruction of ACL tears. The x-axis depicts incremental changes in RR. Gray boxes represent the weighted contribution of each study, with the horizontal black lines representing the 95% CI of the treatment estimate. The heterogeneity was I2 = 0% (0%-46.8%) and was nonsignificant. ACL, anterior cruciate ligament; ACLR, ACL reconstruction; CI, confidence interval; RR, relative risk.
Figure 4.
Figure 4.
Forest plot depicting random-effects model for RR for revision ACLR after primary repair versus reconstruction of ACL tears. The x-axis depicts incremental changes in RR. Gray boxes represent the weighted contribution of each study, with the horizontal black lines representing the 95% CI of the treatment estimate. The heterogeneity was I2 = 0% (0%-46.9%) and insignificant. ACL, anterior cruciate ligament; ACLR, ACL reconstruction; CI, confidence interval; RR, relative risk.
Figure 5.
Figure 5.
Forest plot depicting random-effects model for nongraft-related reoperations after primary repair versus reconstruction of ACL tears. The x-axis depicts incremental changes in relative risk. Gray boxes represent the weighted contribution of each study, with the horizontal black lines representing the 95% CI of the treatment estimate. The heterogeneity was I2 = 42% (0%-72.5%) and was moderate. ACL, anterior cruciate ligament; CI, confidence interval; RR, relative risk.
Figure 6.
Figure 6.
Forest plot depicting random-effects model complications after primary repair versus reconstruction of ACL tears. The x-axis depicts incremental changes in relative risk. Gray boxes represent the weighted contribution of each study, with the horizontal black lines representing the 95% CI of the treatment estimate. The heterogeneity was I2 = 0% (0%-37.7%) and was insignificant. ACL, anterior cruciate ligament; CI, confidence interval; RR, relative risk.
Figure 7.
Figure 7.
Forest plot depicting random-effects model hardware removal after primary repair versus reconstruction of ACL tears. The x-axis depicts incremental changes in relative risk. Gray boxes represent the weighted contribution of each study, with the horizontal black lines representing the 95% CI of the treatment estimate. The heterogeneity was I2 = 0% (0%-61.3%) and was insignificant. ACL, anterior cruciate ligament; CI, confidence interval; RR, relative risk.
Figure 8.
Figure 8.
Forest plot depicting random-effects model for the IKDC score after primary repair versus reconstruction of ACL tears. The x-axis depicts incremental changes in relative risk. Gray boxes represent the weighted contribution of each study, with the horizontal black lines representing the 95% CI of the treatment estimate. The heterogeneity was I2 = 56.9% (0%-81.4%) and was moderate. ACL, anterior cruciate ligament; CI, confidence interval; IKDC, International Knee Documentation Committee; SMD, standardized mean difference.
Figure 9.
Figure 9.
Forest plot depicting random-effects model for the Lysholm score after primary repair versus reconstruction of ACL tears. The x-axis depicts incremental changes in relative risk. Gray boxes represent the weighted contribution of each study, with the horizontal black lines representing the 95% CI of the treatment estimate. The heterogeneity was I2 = 0% (0%-59.9%) and insignificant. ACL, anterior cruciate ligament; CI, confidence interval; SMD, standardized mean difference.
Figure 10.
Figure 10.
Forest plot depicting random-effects model for the Tegner score after primary repair versus reconstruction of ACL tears. The x-axis depicts incremental changes in relative risk. Gray boxes represent the weighted contribution of each study, with the horizontal black lines representing the 95% CI of the treatment estimate. The heterogeneity was I2 = 0% (0%-0%) and was insignificant. ACL, anterior cruciate ligament; CI, confidence interval; SMD, standardized mean difference.
Figure 11.
Figure 11.
Forest plots depicting random-effects model for (A) KOOS-Pain, (B) KOOS-Symptoms, and (C) KOOS-ADL scores after primary repair versus reconstruction of ACL tears. The x-axis depicts incremental changes in RR. Gray boxes represent the weighted contribution of each study, with the horizontal black lines representing the 95% CI of the treatment estimate. ACL, anterior cruciate ligament; ADL, activities of daily living; CI, confidence interval; KOOS, Knee injury and Osteoarthritis Outcome Score; RR, relative risk.
Figure 12.
Figure 12.
Forest plots depicting random-effects model for (A) KOOS-Sport and (B) KOOS-QoL scores after primary repair versus reconstruction of ACL tears. The x-axis depicts incremental changes in RR. Gray boxes represent the weighted contribution of each study, with the horizontal black lines representing the 95% CI of the treatment estimate. ACL, anterior cruciate ligament; CI, confidence interval; KOOS, Knee injury and Osteoarthritis Outcome Score; QoL, quality of life; RR, relative risk; SMD, standardized mean difference.
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