Acute Primary Anterior Cruciate Ligament Repair

The anterior cruciate ligament (ACL) is one of the basic anatomical structures that is frequently affected in sports injuries and provides knee joint stability. In addition to its function of restricting abnormal movements in the knee, the anterior cruciate ligament also serves as a sensory organ (Proprioception: Regulation of muscle contractions according to balance). This is where the difference between anterior cruciate ligament repair and reconstruction surgery emerges. In current studies, it has been observed that when repair and reconstruction are compared, all results are similar, but the sense of balance is better in patients who have undergone repair.

The first publications about anterior cruciate ligament repair started in the 1980s. Although the initial results were good in these studies, it was determined that knee stiffness and ligament failure were observed as time progressed. For this reason, this method was abandoned and the reconstruction process was accepted as the gold standard. When we examine it retrospectively, the reasons why this method failed are; It is applied to all types of tears, surgical techniques are inadequate and postoperative rehabilitation programs are not appropriate.

After an anterior cruciate ligament injury, the torn part of the ligament is usually attached somewhere within the joint. It can be seen during arthroscopy that it is attached to the upper part of the femur, the posterior cruciate ligament, the notch area and the fat pad called Hoffa in front of the knee. If the ligament is not attached to anything, arthroscopy will show that the ligament has disappeared (lysis) after a certain period of time. In histological studies conducted on patients to whom the severed ligament adhered, it was observed that the sensory organs called mechanoreceptors within the ligament were still alive and intact. In short, the stump wants to preserve the vitality of the anterior cruciate ligament by sticking somewhere within the joint. During the repair process, it is ensured that the stump is held in the right place and in the appropriate position.

Which Anterior Cruciate Ligament Tears Can Be Repaired?

Anterior cruciate ligament injuries are classified according to the level along the length of the ligament at which the tear occurs. Tears that occur at the point of attachment to the bone at the top are considered Type 1. If a rupture occurs leaving a small stump in the upper part, it is defined as Type 2, and as it goes down to the lower parts, it is defined as Type 3 and 4. Generally, 80% of the anterior cruciate ligament ruptures from the upper part (Type 1 and 2). If the ligament tears in the middle, which is about a 20% probability, unfortunately it is not repairable.

Anterior cruciate ligament repair can be applied to Type 1 and 2 tears. In type 3 and 4 tears, reconstruction should be performed instead of repair. A good MRI image taken early after the injury will give us information about the level of the tear and whether it is suitable for repair.

When Should Anterior Cruciate Ligament Repair Be Performed?

The ideal patient for repair is Type 1 and 2 tears that are repaired within the first 3 weeks (maximum 6 weeks) after the injury. If the repair is done early, its success will increase accordingly. Early surgery also gives us the chance to perform more meniscus repairs. Accompanying meniscus injuries become more fragmented during the time spent for reconstruction and sometimes become irreparable.

It was previously thought that early surgery for anterior cruciate ligament injury would result in stiffness in the joint called arthrofibrosis. Recent studies have shown that early surgery does not cause joint stiffness.

Does Age Matter in the Patient Who Will Have Anterior Cruciate Ligament Repair?

There is no specific age limit for anterior cruciate ligament repair. It may be preferred in patients who can undergo reconstruction. It provides more advantages than reconstruction in pediatric patients because it does not damage the growth plate.

It has been observed that the rates of re-rupture after repair are higher in patients under the age of 20 compared to other age groups. This is because it is more difficult for this age group to be adequately rehabilitated and the return to sports is earlier. Normally, the average return to sports for a patient who underwent repair is determined as 9 months, whereas in this age group, patients generally return to sports before 4-5 months.

What are the Anterior Cruciate Ligament Repair Techniques?

There are 3 methods for anterior cruciate ligament repair.

• Dynamic intraligamentary stabilization (Implants applied with the second surgery must be removed)
• Augmentation with internal brace
• Primary anterior cruciate ligament repair with suture anchor (the most commonly used method in practice)

Recovery After Acute Primary Anterior Cruciate Ligament Repair

After anterior cruciate ligament repair, the patient must use a knee brace for 4 weeks. We make angle adjustments to our patients weekly and describe the movements they need to do. We want our patients to use crutches and not bear weight on the leg on which she/he had surgery for the first 6 weeks. The period of full return to sports after surgery should be considered as an average of 9 months.

In conclusion;

The earlier repair surgery for selected anterior cruciate ligament injuries is performed after the injury, the better results are obtained. Early surgery increases the chances of success of the treatment as it allows injuries such as meniscus etc. to be treated earlier. It is a more minimal surgery compared to the reconstruction procedure, and the patient has less pain after the surgery. There is no need to take ligaments from another part of the body.

Preserving every original tissue in the body is often desirable, and we should try to preserve our original anterior cruciate ligaments as much as possible. Therefore, it is necessary to consult a doctor early.