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. 2025 Oct 31;14(12):103953.
doi: 10.1016/j.eats.2025.103953. eCollection 2025 Dec.

Primary Arthroscopic Repair of Chronic Anterior Cruciate Ligament Tears

Maximilian M Mueller  1   2 , Valentin Hingsamer  1   3 , Sebastian Conner-Rilk  1   4   5 , Tatiana C Monteleone  1 , Robert J O'Brien  1   6 , Gregory S DiFelice  1
Affiliations

Primary Arthroscopic Repair of Chronic Anterior Cruciate Ligament Tears

Maximilian M Mueller et al. Arthrosc Tech. .

Abstract

In this Technical Note, we present the surgical technique for primary arthroscopic repair of chronic anterior cruciate ligament (ACL) tears. This approach is indicated for proximal type I and II ACL tears with good-to-excellent tissue quality, characterized by an intact synovial sheath and a simple rupture pattern. Compared with acute ACL primary repair, the most significant challenge lies in the careful mobilization and preparation of the scarred ACL remnant. Notably, chronic ACL tears often present with tissue remnants scarred to the posterior cruciate ligament and/or the femoral notch wall, which may still show favorable tissue quality. With meticulous surgical technique and appropriate patient selection, primary arthroscopic repair of chronic ACL tears may therefore remain a viable option beyond the acute phase. Ultimately, tear location and tissue quality should be the primary determinants for selecting ACL primary repair.

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Conflict of interest statement

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: G.S.D. receives royalties, owns stock, and is a paid consultant for Zimmer Biomet; receives royalties from Arthrex; received stock options, provides consulting services, and participates in funded research with Miach Orthopaedics; and receives stock options and provides consulting services for OSSIO. All other authors (M.M.M., V.H., S.C-R., T.C.M., R.J.O.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

Fig 1
Fig 1
Right knee is shown preoperatively. Sagittal-plane T2-weighted MRI (A) and coronal-plane intermediate TE MRI (B) of the right knee displaying a proximal tear (white arrow) of the anterior cruciate ligament (white star) in a 17-year-old male patient. (MRI, magnetic resonance imaging.)
Fig 2
Fig 2
Arthroscopic view from the anterolateral portal of the right knee (patient 1, A and B; patient 2, C and D) showing 2 principal intraoperative scenarios that are commonly observed in the chronic setting after anterior cruciate ligament (ACL) injury. Scenario 1: (A) The ACL remnant is scarred to the posterior cruciate ligament (black arrows). (B) A small portion of the remnant is scarred to the lateral femoral condyle (LFC); (black star). Scenario 2: (C) The ACL remnant is displaced anteriorly. (D) Although the ACL remnant may be mobilizable, the tissue quality is poor, and the ACL stump cannot be adequately reduced to the femoral footprint.
Fig 3
Fig 3
Arthroscopic view from the anterolateral portal of the right knee. (A, B) Separation of the anterior cruciate ligament (ACL) and posterior cruciate ligament using an arthroscopic scissor. (C, D) Placement of the anteromedial (AM) and posterolateral (PL) bundle repair sutures using No. 2 ActivBraid Collagen Co-Braid Sutures from distally to proximally in a Bunnell-type pattern. (E) After a 4.5 × 20-mm hole is punched and tapped at the PL bundle’s anatomical origin with the knee in 115° flexion, an OSSIOfiber suture anchor (black star) is deployed into the lateral femoral condyle (LFC). (F) The PL core sutures are passed from lateral to medial through the proximal PL bundle using a self-retrieving suture passer to perform an additional compression stitch. (F) A tibial tunnel for fixation of the suture augmentation is drilled into the anterior one-third of the ACL’s tibial insertion using a 2.4-mm cannulated pin. (G) Completed Chronic ACL primary repair with suture augmentation (black arrow).
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References

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