Anterior cruciate ligament repair versus reconstruction: A clinical, MRI and patient-reported outcome comparison

There has been a resurgence in anterior cruciate ligament (ACL) repair for proximal tears using modern surgical techniques and technology. This study aims to compare ACL repair with reconstruction using MRI, clinician-measured and patient-reported outcome measures (PROMs).

A post-hoc analysis was performed on prospectively collected data from 20 consecutive primary ACL repairs by the senior author. This was compared with an age and sex-matched cohort of 20 ACL reconstructions by the same surgeon using PROMs, return-to-sport (RTS) testing, and MRI signal noise quotient (SNQ).

Repairs demonstrated equivalent post-operative PROMs to reconstructions as measured by International Knee Documentation Committee subjective score (78.5 ± 17.1 vs. 83.7 ± 13.3, P = 0.333), Tegner Activity Scale (5.9 ± 1.8 vs. 6.1 ± 2.6, P = 0.646) and Lysholm score (89.8 ± 10.0 vs. 89.6 ± 10.4, P = 0.762). There was no difference in repairs and reconstructions passing quadriceps strength criteria (50% vs. 53%, P = 0.097). A greater proportion of repairs passed hamstrings strength criteria (86% vs. 60%, P = 0.023) and hamstrings-to-quadriceps ratio (71% vs. 20%, P = 0.003). There were no differences across hop and Y-balance testing. Repairs had earlier RTS assessment (8.2 ± 2.8 months vs. 10.6 ± 1.4 months, P = 0.020). On 12-month MRI, repairs demonstrated higher femoral (8.8 ± 5.7 vs. 4.6 ± 2.9, P = 0.009) and tibial SNQ (10.0 ± 5.7 vs. 4.3 ± 4.2, P = 0.001), with no mid-substance difference (12.3 ± 8.5 vs. 7.6 ± 5.2, P = 0.074). There were no graft failures.

When patient selection is optimized for proximal tears, ACL repairs demonstrate equivalent PROMs and better objective outcomes to reconstructions at an earlier timepoint. Repair tissue quality on MRI shows higher signal at tibial and femoral attachments.