Primary ACL Repair vs ACL Reconstruction

What is the difference between ACL repair and ACL reconstruction?

Anterior cruciate ligament (ACL) injuries are a significant clinical problem for individuals who participate in pivoting sports (i.e. soccer, lacrosse, American football, basketball, downhill skiing, tennis, pickleball). Knee instability associated with an ACL tear may predispose patients to meniscal injuries, cartilage damage, and eventually osteoarthritis.

The current gold standard in the treatment of ACL injuries is ACL reconstruction. ACL reconstruction utilizes an alternative ligament or tendon source to replace the injured ACL.

Primary ACL repair is currently a hot topic in Orthopedic Surgery and Sports Medicine.  It is important for the ACL-injured patient to have a solid understanding of the benefits, outcomes, and risks of a repair vs a reconstruction as they decide how best to treat their specific injury. Doctor Riley J. Williams provides diagnosis as well as surgical and nonsurgical treatment options for patients in Manhattan, Brooklyn, New York City and surrounding areas who need an expert repair or reconstruction of their ACL.

What is primary ACL repair?

Primary ACL repair involves suturing the torn ACL back together. ACL repair does not utilize a donor graft source. The torn ends of the ACL are trimmed to remove any frayed or damaged tissue, carefully aligned, and sutured together. Alternatively, the torn ACL may be reattached to the bone on which it naturally inserts using sutures and bone tunnels., ACL repair configurations may be reinforced, synthetic scaffolds, biological adjuncts, or other external devices.

Why is there recent renewed interest in primary ACL repair?

Advancements in surgical techniques and technologies have made primary ACL repair more feasible. ACL repair was thoroughly studied in the 1980s and replaced with more modern and effective ACL reconstruction techniques. Surgeons who recommend the ACL procedure as an alternative to ACL reconstruction point out the potential for a shorter recovery time, the idea of preserving a patient’s natural ligament tissue and reduced risk of donor site morbidity as the procedure does not involve harvesting donor tissue graft. Moreover, offering patients the option of ACL repair is also a way for Orthopedic Surgeons to differentiate themselves from other knee surgeons.

Does primary ACL repair have a lasting positive outcome?

While primary ACL repair can be a viable option for a small subset of patients with ACL tears, it is not suitable for most patients, especially those patients who actively participate in pivoting sports. The clinical success rates of the ACL repair are inferior to ACL reconstruction; moreover, revision rates of ACL repair patients far exceed those observed for ACL reconstruction patients. Failure rates of ACL repair procedures are especially high in young patients (age less than 30 years) who participate in ballistic, high demand sports. Patients considering primary ACL repair should seek a second opinion from an orthopedic surgeon who specializes in the treatment of ACL injuries to confirm the appropriateness of ACL repair in their specific circumstance.

Doctor Williams’ practice specializes in the treatment of knee ligament injuries; he performs a high volume of both primary and revision ACL surgeries. Unfortunately, many of these revision ACL surgeries are performed on patients who underwent primary ACL repairs from other practices. ACL repair does have a place in the continuum of ACL treatment options following ACL injury.  It is a reasonable option in lower demand, older patients.

Facts about primary ACL repair surgery?

• Primary ACL repair is typically only considered for patients with a proximal (femoral) avulsion tear (the ligament is pulled away from the bone); other tear configurations (i.e. mid-substance) are less optimal for current ACL repair methods.
• Suturing a torn ACL back without causing additional damage to the ligament requires a high level of surgical skill and expertise, making it potentially more challenging than ACL reconstruction surgery.
• The success rates of primary ACL repair are generally poorer than those of ACL reconstruction, particularly for athletes or individuals with high activity levels. The repaired ACL is more prone to re-tearing and may not provide the same stability as a reconstructed ACL.
• While a shorter recovery time is often one of the benefits touted for primary ACL repair, the recovery time is often actually longer than after ACL reconstruction because the repaired ACL needs time to heal and regain strength.  Oftentimes, ACL repair patients must be immobilized early in the rehab process to facilitate ligament healing. This can result in knee stiffness and loss of leg strength.
• The long-term results and durability of current ACL repair methods are unknown.

Is primary ACL repair less expensive than ACL reconstruction?

ACL repair is not less expensive than ACL reconstruction.

Does primary ACL repair surgery take less time than ACL reconstruction?

No. Skilled ACL surgeons should be able to complete a primary ACL repair or ACL reconstruction in under an hour.

What is the take home message for ACL repair vs reconstruction?

Although ACL repair is an emerging approach in the treatment of the ACL injured patient, clinical results and revision rates of primary ACL repair are inferior to ACL reconstruction. Patients should consult with a surgeon well-versed in the treatment of these injuries before moving ahead with either ACL repair or ACL reconstruction.