Translate this page into:
Repair with suture tape augmentation vs. reconstruction for ACL tears: A systematic review and meta-analysis
, Elcio Machinskic, Vinícius Furtado da Cruzd, Bruno Butturi Varonee,, Riccardo Gomes Gobbie, Camilo Partezani Helitoe, Daniel Peixoto Leale
⁎Corresponding author: Bruno Butturi Varone. brunobutturivarone@yahoo.com.br
-
Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Interest in repairing ruptured anterior cruciate ligaments (ACL) has resurged, with suture tape augmentation (internal brace, ACL-IB) emerging as a prominent technique. However, the efficacy of ACL-IB compared to ACL reconstruction (ACL-R) remains unclear. We conducted a meta-analysis to address this gap.
Adhering to PRISMA guidelines, a search to PubMed, EMBASE and Cochrane Central for studies comparing ACL-IB to ACL-R was performed. The main endpoints were patient-reported outcomes (PROs) and failure rate. Muscle and joint function and surgery time were also assessed. Statistical analysis was performed by Review Manager 5.1.7.
Nine studies comprising 1049 patients were included; 381 (36.3 %) underwent ACL-IB. Hamstring autografts were used for ACL-R in 421 patients (63.0 %). Most studies (6 of 8) reported follow-up longer than two years. The failure rate was higher in the ACL-IB group (risk ratio 3.62; 95 % CI 1.16 to 11.33; p = 0.03; I2: 52 %). No significant difference was found between groups for PROs, except KOOS Symptoms, which was significantly improved with ACL-IB (mean difference 2.49; 95 % CI 0.05 to 4.92; p = 0.05; I2: 0 %). ACL-IB resulted in stronger hamstrings (mean difference 11.99 %; 95 % CI 4.47 %–19.51 %; p = 0.002; I2: 73 %). No significant difference was found in anterior tibial translation and quadriceps strength.
ACL-IB had a higher failure rate compared to ACL-R. However, ACL-IB showed better hamstring strength and KOOS symptom score. No significant differences were seen in other PROs, time to return to sports, or quadriceps strength.
Keywords
Anterior cruciate ligament
Failure rate
Internal brace
Reconstruction
Repair
Suture tape augmentation
1 Introduction
The anterior cruciate ligament (ACL) is a crucial stabilizing structure of the knee, extending from the medial aspect of the lateral femoral condyle to the anterior tibial spine. Its primary functions include controlling the anterior translation of the tibia and providing restraint to tibial rotation.1 There is considerable interest in the treatment of ACL tears, as these injuries are both common and debilitating for competitive and recreational athletes.2 Initially, open primary repair was the standard surgical approach, popular until the development of arthroscopy.3–5 Due to complications from surgical practices and rehabilitation protocols used at the time, there was a paradigm shift, and arthroscopic ACL reconstruction (ACL-R) has become the gold standard.6–8
ACL-R has significantly evolved over the past decades, with surgical techniques differing primarily in tunnel drilling, fixation, and graft choice. Although ACL-R is associated with effective and reliable outcomes, several deficiencies have been realized.9,10 First, autograft ACL-R requires graft harvesting, which can lead to donor site complications such as anterior knee pain, kneeling pain for patellar tendon grafts, and reduced hamstring strength for hamstring grafts.7,11 Additionally, nerve endings are extracted along with the native ligament hindering proprioception.7,12 Furthermore, reconstruction necessitates an extensive rehabilitation period.11 These issues led to recent investigations into ACL repair again, as it could theoretically prevent these complications.12,13 Repair surgeries have been modernized, and new surgical techniques have emerged.12 Consequently, this renewed interest has prompted the development of several trials and meta-analyses to determine if modern ACL repair can be a viable alternative to ACL-R. However, the available meta-analyses compare ACL-R with all repair techniques without distinguishing between them, which can create confusion regarding the optimal technique choice.14–20
Therefore, a meta-analysis was conducted to evaluate whether the technique of anterior cruciate ligament repair with suture tape augmentation (ACL-IB) offers functional benefits and fewer complications compared to anterior cruciate ligament reconstruction (ACL-R) in patients who suffered from an ACL rupture. We hypothesize that the results of both techniques will be similar.
2 Methods
This systematic review and meta-analysis were conducted and reported following the guidelines of the Cochrane Collaboration Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement.21,22 The meta-analysis protocol was prospectively registered at PROSPERO on May 16, 2024. PROSPERO ID: CRD42024543703.
2.1 Definitions
The ACL-IB consists of preserving the remaining ACL, which is fixed in conjunction with a suture tape as internal bracing. Any femoral and tibial fixation option (suspensory cortical button, anchor, or interference screw) was allowed as a fixation method (detailed information on the repair techniques used in each study is presented in Supplementary Appendix; Table A1).
On the other hand, ACL-R involves an arthroscopic procedure in which the native ACL remnant is debrided, followed by reconstruction of a new ligament using a graft. All graft types and fixation methods were included.
2.2 Study eligibility (inclusion and exclusion criteria)
In this meta-analysis, only the studies that met the following eligibility criteria were included: (1) clinical studies, either retrospective or prospective design; (2) enrolled patients with ACL tears; (3) compared an anterior cruciate ligament repair augmented with suture tape to ACL-R performed with autograft; (4) reported any of the outcomes of interest. There were no restrictions regarding the type of autograft used for reconstruction.
Exclusion criteria were: (1) absence of a control group of ACL-R; (2) studies not published in English; and (3) inclusion of patients with multi-ligamentous knee injury. For studies with overlapping populations, only the one with the highest number of patients was included unless the overlapping studies reported different outcomes. This approach avoids duplicating information in the same outcome's forest plot.
2.3 Literature search
In May 2024, a systematic search was performed on PubMed (MEDLINE), EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) without date restrictions. Our search strategy included the following terms: ‘anterior cruciate ligament’, ‘ACL’, ‘suture tape’, ‘internal brace’, ‘reconstruction’, and ‘ACLR’. The complete search strategy is presented in the Supplementary Appendix. The search was performed independently by two authors, avoiding the omission of potential studies.
2.4 Study selection and data abstraction
The literature search yielded a total of 2694 studies among the three databases. The study selection was conducted with the Rayyan web-based software. After removing duplicates, two authors (R.A.C. and A.R.S.O.F.) independently screened titles and abstracts and assessed full text for inclusion based on prespecified criteria. Disagreements were resolved by consensus, involving a third author (D.P.L). Additionally, we employed backward snowballing (i.e., review of references) to identify relevant articles derived from the original search.
All data related to the endpoints of interest were extracted from the selected studies. Two authors independently extracted the data (R.A.C. and E.M.). The information was recorded in two different Excel spreadsheets and then compared. Disagreements were resolved by consulting a third author (D.P.L).
2.5 Risk of bias assessment
The methodological quality and risk of bias of the individual studies were independently assessed by two authors (R.A.C and D.P.L.) using the Cochrane Collaboration tool for assessing the risk of bias in non-randomized studies (ROBINS-I).23 With this tool, we assessed each study's risk of bias through seven domains: confounding, selection, classification, deviations from intended interventions, missing data, and selection of reported results. Disagreements were resolved by consensus. The publication bias was also investigated by the funnel-plot analysis of point estimates concerning study weights. Following Cochrane's recommendations, Egger's test was not performed due to the inclusion of fewer than ten studies in this meta-analysis. Leave-one-out and subgroup analyses were also conducted to mitigate study biases.
2.6 Data analysis
The primary endpoints measured were failure rate, defined as the need for revision surgery due to ACL injury or confirmed re-ruptured, and patient-reported outcomes (PROs), such as the Lysholm score, International Knee Documentation Committee (IKDC) score, and Knee Injury and Osteoarthritis Outcome (KOOS) scores. We included three outcomes for muscle and joint function (hamstring strength, quadriceps strength, and anterior tibial translation). For hamstring and quadriceps strength, we considered data that presented the strength of the operated side as a percentage of the uninjured side. For anterior tibial translation, we included the studies that reported the side-to-side difference (translation of the uninjured side subtracted from the translation of the operated side). Operation time and return to sport were also recorded as outcomes.
For binary endpoints, we used the Mantel–Haenszel model with risk ratio (RR) with 95 % confidence intervals as the measure of effect size. We used mean difference (MD) with 95 % confidence intervals for continuous endpoints. Random effects methods were used to analyze the data for both binary and continuous endpoints. Information uniformity was assessed with the Cochran Q test and I2 statistics; p-values <0.10 and I2 > 25 % were considered significant for heterogeneity. Review Manager 5.4.1 (Cochrane Centre, The Cochrane Collaboration, Denmark) was used for statistical analysis.
We performed a sensitivity analysis using the leave-one-out method for the selected high heterogeneity outcomes. By iteratively removing one study at a time, we could minimize the impact of potential confounders, thus controlling for publication bias. Furthermore, prespecified subgroup analyses included data restricted to (1) reconstruction performed with hamstring tendons as autograft; (2) and studies with longer-term (≥2 years) follow-up. These analyses were performed exclusively in instances where stratification enabled a comparison among data from three or more studies.
3 Results
3.1 Study selection and characteristics
Our systematic research yielded 2694 potential articles. After removing duplicates and ineligible studies, twenty-seven were selected for the full review. Of these, 9 studies met all the inclusion criteria and were included in our meta-analysis (Fig. 1).
A total of 1049 patients were included in the analysis, 381 (36.3 %) underwent the ACL-IB intervention and 668 (63.7 %) underwent ACL-R. Detailed information about the required criteria for inclusion in the groups for each study is presented in Supplementary Appendix; Table A2. A hamstring autograft was used for ACL reconstruction on 421 patients. Studies baseline characteristics are reported in Table 124–32
| Study | Design | Patients IB | Patients ACLR | Female, (%) IB/ACLR | Ageg, y IB/ACLR | BMIg, IB/ACLR | Injury to surgery c, d IB/ACLR | Meniscal lesions, (%) IB/ACLR | Follow-upg, mo IB/ACLR |
| Douoguih 2024 | Nonrandomized prospective study | 30a | QPA: 17aBPTB: 13a | 56.7/53.3 | 27.5/25.5 | 25.3/24.2 | NA | NA | 24e |
| Gagliardi 2019 | Retrospective | 22 | QPA: 157 | 45.5/52.2 | 13.9/15.7 | 0.7/1.0 b | 33/42 | 54.5/59.2 | 39/33 c |
| Hopper 2022 | Retrospective | 134 | 4SHG: 272 | 44/18 | 35/28 | NA | 30/360 | 3.7/3.3 | 60 c |
| Mattiassich 2021 | Cross-sectional observational study | 27 | HG: 23 | 63/43 | 35.4/33.8 | 24.4/24.9 | 16g | NA | (12–18) d |
| RetroBrace 2023 | Retrospective | 29 | HG: 27 | 55.2/51.8 | 36.8/37.0 | 25.5/24.5c | 20/28 | 90/100 | 24.4/24.2c |
| SANTI 2022 | Retrospective | 75 | HG: 62BPTB: 13 | 61.3/64 | 40/37.6 | 23/23.1 | 66/69 | 17.3/22.6 | 24e |
| Szwedowski 2021 | Retrospective | 11 | HG: 15 | 45.4/NA | 36/NA | NA | NA | NA | 14.8/13.6 |
| Van Der List 2017 | Retrospective | 34 | HG: 3BPTB: 47 | 42.3/38.8f | 33/29f | 25/26f | 48/412f | 32.7/58.9f | NR |
| Wilson 2023 | Nonrandomized prospective study | 19 | 4SHG: 19 | 42.1/31.6 | 29.8/28.0 | 26.0/27.4 | NA | NA | 52/51 |
The mean age was 31.9 years in the ACL-IB group and 29.3 years in the ACL-R group. Only one study focused on adolescent patients.25 The ACL-IB group had a higher percentage of female patients (52.5 %) compared to the ACL-R group (39.8 %), but there was no significant difference (p = 0.20). No statistically significant difference was found in time from injury to surgery (p = 0.16). Most studies (6 out of 8) reported outcomes with a follow-up period longer than two years, while two studies had shorter follow-ups.
3.2 Pooled analysis of all studies
3.2.1 Failure rate
The failure rate was reported in six studies (Fig. 2). The rates of failure were significantly higher with ACL-IB (34/303; 11.2 %) as compared to ACL-R (35/569; 6.1 %) group (RR 3.62; 95 % CI 1.16 to 11.33; p = 0.03; I2: 52 %).
3.2.2 Patient-reported outcomes
There was no significant difference between groups for the following patient-reported outcomes: Lysholm (MD 1.27; 95 % CI -1.16 to 3.71; p = 0.31; I2 = 0 %; Fig. 3A), IKDC (MD 0.76; 95 % CI -1.57 to 3.09; p = 0.52; I2: 0 %; Fig. 3B), KOOS Quality of Life (MD 2.75; 95 % CI -1.79 to 7.30; p = 0.23; I2: 0 %; Fig. 3C), KOOS Pain (MD 0.37; 95 % CI -1.53 to 2.27; p = 0.71; I2: 8 %; Fig. 3D), KOOS Activities of Daily Living (MD 0.00; 95 % CI -0.70 to 0.70; p = 1.00; I2: 0 %; Fig. 3E), KOOS Sport and Recreation (MD -0.25; 95 % CI -4.50 to 4.00; p = 0.91; I2: 0 %; Fig. 3F). Nonetheless, KOOS Symptoms was significantly improved following ACL-IB compared to the ACL-R (MD 2.49; 95 % CI 0.05 to 4.92; p = 0.05; I2: 0 %; Fig. 4).
3.2.3 Muscle and joint function
The hamstring was significantly stronger in patients who underwent ACL-IB compared to the patients who underwent ACL-R (MD 11.99 %; 95 % CI 4.47 %–19.51 %; p = 0.002; I2: 73 %; Fig. 5A). In contrast, no significant difference was found between groups in terms of quadriceps strength (MD 3.89 %; 95 % CI -0.20 %–7.98 %; p = 0.06; I2: 0 %; Fig. 5B), and side-to-side anterior tibial translation (MD 0.38 mm; 95 % CI -0.30 mm–1.06 mm; p = 0.27; I2: 78 %; Fig. 5C).
3.2.4 Return to sport
No significant difference was found between ACL-IB and ACL-R in terms of return to sport (RR 1.13; 95 % CI 0.94 to 1.36; p = 0.18; I2: 0 %; Fig. 6).
3.2.5 Operation time
Two articles reported operation time.26,32 In one of them, the mean duration for ACL-R and ACL-IB surgeries was 97 min (SD: 28.5) and 81 min (SD: 23.7), respectively.26 The other study also reported shorter operation time in the ACL-IB group, with a mean of 97 min (SD: 15), compared to a mean of 129 min (SD: 32) for the ACL-R group.32 The ACL-IB procedure was associated with a significant reduction in operation time compared to the ACL-R procedure (MD –24.50 m; 95 % CI -40.50 m to −8.86 m; p = 0.002; I2: 68 %; Fig. 7).
3.3 Subgroup analyses
There was not significant difference between ACL-IB versus ACL-R when stratified by longer-term (≥2 years) follow-up or reconstructions performed with hamstring tendons as autograft for IKDC and anterior tibial translation. Data presented in Supplementary Appendix; Figs. A1 and A2.
3.4 Sensitivity analysis
Due to heterogeneity, we performed a leave-one-out sensitivity analysis for both anterior tibial translation and failure. Regarding anterior tibial translation, the exclusion of one study notably impacted the statistics, changing the mean difference to 0.66 mm (95 % CI 0.19 mm–1.12 mm; p = 0.006; I2:52 %), thus favoring ACL-R.28 That study was pivotal in driving the overall pooled result toward no significant difference. The exclusion of the other studies separately did not alter the statistics. For failure rate, the exclusion of three studies, one at a time, led to risk ratios ranging from 1.56 to 3.43 with the 95 % CI spanning from 0.94 to 12.41, indicating that there would be no significant difference between the groups.25,27,31 The exclusion of the other studies one at a time did not alter the advantage seen with ACL-R.
3.5 Quality assessment and publication bias
Individual appraisal of the domains of each study included in the meta-analysis is shown in Supplementary Appendix; Fig. A3. Overall, studies were classified as having a moderate risk of bias. The domains of confounding and patient selection showed that most judgments are of moderate risk (6 out of 9). In the confounding domain, two studies used appropriate analysis methods that adjusted for all important confounding variables.25,27 In the patient selection domain, two studies were prospective and were classified as low risk.29,31 A funnel plot analysis was performed for the endpoint with the largest number of studies included. For anterior tibial anteriorization, the plot was symmetrical with one exception, suggesting publication bias for this study (Supplementary Appendix; Fig. A4).28
4 Discussion
In this systematic review and meta-analysis of 9 studies and 1049 patients, we compared ACL-IB versus ACL-R for ACL ruptures. The main findings include: (1) the failure rate is higher after ACL-IB; (2) there was no significant difference between groups for return to sport, quadriceps strength, anterior tibial translation, and most of the PROs; (3) KOOS Symptoms, the PROs exception, is improved with ACL-IB; (4) ACL-R is associated with a weaker hamstring; (5) and ACL-IB reduced operation time by 24 min.
Although ACL-R is currently the gold standard intervention to treat ACL tears, the discussion about ACL repair has become more popular over the last years.7,11 New repair techniques have arisen, such as dynamic intraligamentary stabilization (DIS), ACL-IB, and bridge-enhanced ACL repair (BEAR).12,33 These surgical approaches - especially for ACL proximal avulsion - are believed to resolve most of the ACL-R downsides, such as harsh rehabilitation period and donor-site-related complications.12,13 On the other hand, repair has been historically associated with other deficiencies, namely re-injury and knee laxity.6,32
Many available studies scrutinized the comparison between repair and reconstruction, disregarding the different repair techniques. The prognosis of open ACL repair was noted to be relatively unsatisfactory as opposed to arthroscopic ACL repair and ACL-R.19 Arthroscopic ACL repair is reported to have comparable clinical efficacy and PROs and even improved functional performance.17–19 For failure and knee laxity, we noted conflicting conclusions in the literature. However, the more comprehensive and recent meta-analysis stated that ACL repair demonstrated significantly greater joint laxity and failure rate and, consequently, ACL-R should be recommended for primary ACL tears.18
In addition, studies explored the comparison of specific ACL repair techniques and ACL-R. For instance, a meta-analysis of 429 patients showed that DIS has comparable knee laxity, IKDC scores, and Tegner scores, along with better Lysholm scores.34 However, it had a higher rate of implant removal as compared to reconstruction. In addition, the failure rate for DIS was 22.0 % compared to 15.6 % for reconstruction.34 Another study reported a 10 % reoperation rate and a 29 % rate of hardware removal, being both the highest among the techniques compared.33 For BEAR, a meta-analysis of 2 prospective studies, comprising 120 patients, showed no differences in muscle strength (quadriceps and hip abductors), knee laxity, and scores.35 However, BEAR is associated with incremented hamstring strength, earlier return to activities, and fast symptom relief.35 For failure rate, 14 % of the BEAR group and 6 % of the ACLR group had a reinjury that required a second ACL surgical intervention.36
Two endpoints were not analyzed using forest plots due to limited pooled data. These outcomes included pain intensity measured by the Visual Analogue Scale (VAS) and Tegner score. For pain, one study reported VAS scores of 2.8 for ACL-IB and 4.1 for ACL-R, while another found a slight advantage of 0.1 in favor of the repair technique.31,37 Both studies indicated that ACL-IB was associated with less postoperative pain, possibly due to the less invasive nature of the repair technique. However, the limited amount of data diminishes the robustness of this finding. Regarding the Tegner score, analysis was not feasible as preoperative values were inconsistently measured; some studies recorded it before injury, others after. Two studies comparing pre-injury and post-surgery scores showed a significant advantage for ACL-IB over ACL-R (MD 0.1; 95 % CI 0.02 to 0.18; p = 0.009; I2: 0 %).27,29 Additional data are needed to strengthen these findings.
Overall, our meta-analysis aligns with the literature showing higher failure rates in LCA repair compared to reconstruction.17,18,20 Additionally, there was no statistically significant difference in most PROs, except for KOOS symptoms, where ACL-IB had a slight advantage and greater hamstring strength in the ACL-IB group. The KOOS symptoms subscale measures knee-related issues such as swelling, sensations of grinding or clicking, locking or catching during movement, as well as the ability to fully straighten or bend the knee. One possible explanation for the improved KOOS symptoms scores in the ACL-IB group, as compared to reconstruction, could be that ACL repair avoids the harvesting of graft tissue, which leads to less tissue disruption and damage. In contrast, ACL reconstruction involves graft harvesting, which may contribute to increased tissue degradation and inflammation, thus affecting symptoms like swelling or mechanical knee issues. For other subscales, such as pain or function, these factors may also play a role; however, it is possible that the available data did not provide enough input to detect a statistically significant difference between the two techniques.
In contrast to existing literature, our study demonstrated similar anterior tibial translation values between both techniques, whereas the literature indicates greater ligament laxity in ACL-IB cases.17,18 In our study, even in the sensitivity analysis, where the study responsible for a large portion of the heterogeneity was removed, the recalculated mean difference remained at 0.66 mm, which is within the noninferiority margin of 2.0 mm for side-to-side laxity difference.27,28 The discussion regarding LCA repair has arisen intending to avoid patient graft harvesting and preserve neuroreceptors within the ligament, theoretically preserving joint proprioception.7 However, given the higher failure rate in ACL-IB and the lack of early return to sports with this technique, these findings do not encourage the adoption of this surgical practice.
As a study limitation, none of the included studies performed randomization of patients evaluated with proximal LCA tears (Sherman types 1 and 2) to ACL-IB and ACL-R groups. Given the scarcity of RCTs in the current literature and the growing academic interest in this area, we conducted a meta-analysis pooling the available non-randomized studies. Future RCTs are suggested to provide more definitive conclusions on the optimal approach. Second, although both groups from the studies included ACL ruptures, the lesions in the repair group were typically proximal and more recent. However, even with greater intervals, reconstruction showed lower failure rates. Another limitation was the variability in the ACL-R group between the studies, mainly because of the graft choice. To mitigate the effect of different graft choices on a patient's prognosis, we performed a subgroup analysis for hamstring autograft. Also, there were two studies with shorter-term follow-up (<2 years). So, we conduct other subgroup analyses with long-term follow-up. Both subgroup analyses did not demonstrate differences in comparison to the non-stratified analysis. In addition, there was a variability in the methods used to register anterior tibial translation. Most of the methods are conducted manually. This explains, in part, the high heterogeneity observed in statistics.
5 Conclusion
The findings revealed that ACL-IB had a higher failure rate compared to ACL-R. However, ACL-IB demonstrated improved hamstring strength and KOOS symptom scores. No statistically significant differences were observed in other patient-reported outcomes, time to return to sports or quadriceps strength.
CRediT authorship contribution statement
Rodrigo Arruda Conde: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing – original draft. André Richard da Silva Oliveira Filho: Data curation, Investigation, Writing – original draft. Elcio Machinski: Data curation, Formal analysis, Software, Writing – original draft. Vinícius Furtado da Cruz: Formal analysis, Software, Writing – original draft. Bruno Butturi Varone: Conceptualization, Methodology, Writing – review & editing. Riccardo Gomes Gobbi: Supervision, Writing – review & editing. Camilo Partezani Helito: Conceptualization, Supervision, Validation, Writing – review & editing. Daniel Peixoto Leal: Conceptualization, Methodology, Project administration, Supervision, Validation, Writing – review & editing.
Patient consent
This manuscript is a systematic review and meta-analysis of available published literature. No new patient data was collected from patients, and no procedures were performed on human subjects.
Ethical statement
This manuscript is a systematic review and meta-analysis of available published literature. All human subject's data in this manuscript was attained from previously published works, and Institutional Review Board approval was not required.
Funding sources
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
References
- Stiffness and laxity of the knee--the contributions of the supporting structures. A quantitative in vitro study. JBJS. 1976;58(5):583-594.
- [Google Scholar]
- Epidemiology of anterior cruciate ligament reconstruction: trends, readmissions, and subsequent knee surgery. JBJS. 2009;91(10):2321-2328.
- [Google Scholar]
- VI. Ruptured crucial ligaments and their repair by operation. Ann Surg. 1903;37(5):716.
- [Google Scholar]
- The anterior cruciate ligament: a technique of repair and reconstruction. Clin Orthop Relat Res. 1979;143:97-106.
- [Google Scholar]
- Long-term follow-up after primary repair of the anterior cruciate ligament: clinical and radiological evaluation 15–23 years postoperatively. Arch Orthop Trauma Surg. 2005;125:217-221.
- [Google Scholar]
- Primary repair of the anterior cruciate ligament: a paradigm shift. Surgeon. 2017;15(3):161-168.
- [Google Scholar]
- Incidence and trends of anterior cruciate ligament reconstruction in the United States. Am J Sports Med. 2014;42(10):2363-2370.
- [Google Scholar]
- Anterior cruciate ligament injuries: anatomy, physiology, biomechanics, and management. Clin J Sport Med. 2012;22(4):349-355.
- [Google Scholar]
- Hamstring autograft versus patellar tendon autograft for ACL reconstruction: is there a difference in graft failure rate? A meta-analysis of 47,613 patients. Clin Orthop Relat Res. 2017;475(10):2459-2468.
- [Google Scholar]
- ACL repair: a game changer or will history repeat itself? A critical appraisal. J Clin Med. 2021;10(5):912.
- [Google Scholar]
- Efficacy of nonaugmented, static augmented, and dynamic augmented suture repair of the ruptured anterior cruciate ligament: a systematic review of the literature. Am J Sports Med. 2020;48(14):3626-3637.
- [Google Scholar]
- Patients forget about their operated knee more following arthroscopic primary repair of the anterior cruciate ligament than following reconstruction. Arthrosc J Arthrosc Relat Surg. 2020;36(3):797-804.
- [Google Scholar]
- Anterior cruciate ligament repair outcomes: an updated systematic review of recent literature. Arthrosc J Arthrosc Relat Surg. 2019;35(7):2233-2247.
- [Google Scholar]
- Primary repair with suture augmentation for proximal anterior cruciate ligament tears: a systematic review with meta-analysis. Knee. 2022;38:19-29.
- [Google Scholar]
- Early outcomes of primary repair versus reconstruction for acute anterior cruciate ligament injury: a systematic review and meta-analysis. Medicine. 2022;101(51)
- [Google Scholar]
- Arthroscopic anterior cruciate ligament repair versus autograft anterior cruciate ligament reconstruction: a meta-analysis of comparative studies. Frontiers in Surgery. 2022;9
- [Google Scholar]
- Reduced knee laxity and failure rate following anterior cruciate ligament reconstruction compared with repair for acute tears: a meta-analysis. J Orthop Traumatol. 2023;24(1):8.
- [Google Scholar]
- Efficacy of repair for ACL injury: a meta-analysis of randomized controlled trials. Int J Sports Med. 2022;43(13):1071-1083.
- [Google Scholar]
- Clinical results of primary repair versus reconstruction of the anterior cruciate ligament: a systematic review and meta-analysis of contemporary trials. Orthopaedic Journal of Sports Medicine. 2024;12(6)
- [Google Scholar]
- The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Br Med J. 2021;372
- [Google Scholar]
- ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. Br Med J. 2016;355
- [Google Scholar]
- Clinical and radiological results after Internal Brace suture versus the all-inside reconstruction technique in anterior cruciate ligament tears 12 to 18 months after index surgery. Sportverletz Sportschaden. 2021;35(2):103-114.
- [Google Scholar]
- ACL repair with suture ligament augmentation is associated with a high failure rate among adolescent patients. Am J Sports Med. 2019;47(3):560-566.
- [Google Scholar]
- Favorable Patient-Reported, clinical, and functional outcomes 2 years after ACL repair and InternalBrace Augmentation compared with ACL Reconstruction and healthy controls. Am J Sports Med. 2023;51(12):3131-3141.
- [Google Scholar]
- The minimal clinically important difference, patient acceptable symptom state, and clinical outcomes of anterior cruciate ligament repair versus reconstruction: a matched-pair analysis from the SANTI study group. Am J Sports Med. 2022;50(13):3522-3532.
- [Google Scholar]
- The comparison of clinical result between primary repair of the anterior cruciate ligament with additional internal bracing and anatomic single bundle reconstruction—a retrospective study. J Clin Med. 2021;10(17):3948.
- [Google Scholar]
- Deficits in muscle strength are not seen following recovery from augmented primary repair of anterior cruciate ligament tears. Journal of ISAKOS. 2023;8(6):436-441.
- [Google Scholar]
- Comparable rates of secondary surgery between anterior cruciate ligament repair with suture tape augmentation and anterior cruciate ligament reconstruction. Journal of Experimental Orthopaedics. 2022;9(1):115.
- [Google Scholar]
- Suture-augmented anterior cruciate ligament repair for proximal avulsion or high-grade partial tears shows similar side-to-side difference and no clinical differences at two years versus conventional anterior cruciate ligament reconstruction for mid-substance tears or poor anterior cruciate ligament tissue quality. Arthrosc J Arthrosc Relat Surg. 2024;40(3):857-867.
- [Google Scholar]
- Range of motion and complications following primary repair versus reconstruction of the anterior cruciate ligament. Knee. 2017;24(4):798-807.
- [Google Scholar]
- Arthroscopic primary repair of proximal anterior cruciate ligament tears seems safe but higher level of evidence is needed: a systematic review and meta-analysis of recent literature. Knee Surg Sports Traumatol Arthrosc. 2020;28:1946-1957.
- [Google Scholar]
- Clinical outcomes in dynamic intraligamentary stabilization technique for anterior cruciate ligament tear: a meta-analysis. Medicine. 2023;102(10)
- [Google Scholar]
- Bridge enhanced ACL repair vs. ACL reconstruction for ACL tears: a systematic review and meta-analysis of comparative studies. SICOT-J. 2023;9
- [Google Scholar]
- Bridge-enhanced anterior cruciate ligament repair is not inferior to autograft anterior cruciate ligament reconstruction at 2 years: results of a prospective randomized clinical trial. Am J Sports Med. 2020;48(6):1305-1315.
- [Google Scholar]
- A comparison of postoperative pain between anterior cruciate ligament reconstruction and repair. Eur J Orthop Surg Traumatol. 2021;31:1403-1409.
- [Google Scholar]