Abstract
Background
Anterior cruciate ligament (ACL) reconstruction remains the gold standard but carries donor-site morbidity and prolonged recovery. Modern ACL repair techniques theoretically preserve native proprioception and enable faster rehabilitation. We hypothesized that modern ACL repair would demonstrate non-inferior clinical outcomes compared to reconstruction.This meta-analysis compares clinical outcomes of primary repair versus autograft reconstruction.
Methods
We systematically searched PubMed, Cochrane Library, and Web of Science (2015–2025) for comparative studies (RCTs, cohorts, case-controls) reporting ≥ 2 key outcomes (failure rate, AP knee laxity, IKDC, Lysholm, or Tegner scores) with ≥ 1-year follow-up. Pooled ORs and WMDs with 95% CIs were calculated using RevMan 5.4. Subgroup analyses (injury-to-surgery time, injury location, study design, repair technique) and GRADE assessment were performed.
Results
Fourteen studies (4 RCTs, 8 cohorts, 2 case-controls; n = 908 patients) were included (repair: n = 460; reconstruction: n = 448). Failure/Revision Rates: Repair demonstrated numerically higher failure rates (OR = 2.24, 95% CI 1.30–3.86, P = 0.004) and revision rates (OR = 2.01, 95% CI 1.21–3.33, P = 0.007) versus reconstruction.Hardware removal: increased hardware removal incidence was observed in repair groups (OR = 8.19, 95% CI 2.89–23.20, P < 0.001).AP knee laxity: reconstruction showed marginally lower AP knee laxity (WMD = 0.30, 95% CI 0.06–0.53, P = 0.01).Patient-reported outcomes: no significant differences in IKDC (WMD = 1.31,95%CI: −0.01–2.63;P = 0.05) or Tegner scores (WMD: 0.01; 95% CI: -0.28– 0.30;P = 0.94). Lysholm scores slightly favored reconstruction (WMD = 1.62,; 95% CI: 0.35–2.89;P = 0.01).Key subgroup findings: repair achieved comparable outcomes to reconstruction in: (1) RCT-designed studies, (2) Acute repairs (< 21 days post-injury).
Conclusions
ACL repair is associated with higher failure and revision rates than reconstruction overall, but may be a viable alternative in selected patients with acute proximal tears.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12893-025-03101-6.
Keywords: Anterior cruciate ligament, Repair, Reconstruction, Meta-analysis, Acute proximal injury
Introduction
Anterior cruciate ligament (ACL) injury is one of the most common ligament injuries, with an annual incidence of approximately 68.6 per 100,000 individuals, accounting for over 50% of all knee injuries [1]. The primary goals of ACL injury management are to restore knee stability and kinematics, improve mobility, and reduce the risk of meniscal tears and early-onset osteoarthritis. Due to the ligament’s limited self-healing capacity, surgical intervention is often required.
Currently, autograft reconstruction remains the global gold standard for ACL injury treatment. However, this approach has significant limitations: (1) donor site morbidity, including proprioceptive deficits and reduced athletic function secondary to tendon harvesting; (2) complications such as muscle atrophy or necrosis at the harvest site; and (3) prolonged postoperative recovery periods [2, 3]. In contrast, ACL repair techniques offer theoretical advantages, including the preservation of the native ligament structure, which may enhance postoperative proprioception. Furthermore, repair procedures are less invasive, facilitating faster rehabilitation, avoid the need for large bone tunnels, and potentially allow for easier revision reconstruction if necessary [4].
Over the past decade, novel techniques such as Suture Anchor Repair (SAR), Dynamic Intraligamentary Stabilization (DIS), Bridge-Enhanced ACL Repair (BEAR), and Internal Brace Ligament Augmentation (IBLA) have revitalized interest in primary repair [5]. These advancements leverage improved implant design (e.g., bioabsorbable anchors), high-tension sutures, and arthroscopic precision to enhance biomechanical stability and healing potential, addressing the limitations of historical open repair techniques. Recently published randomized controlled trials and cohort studies in high-impact journals reporting favorable outcomes for modern repair techniques have stimulated renewed academic interest [5, 6].
This study aims to evaluate the feasibility of innovative ACL repair techniques as an alternative to reconstruction for ACL injuries through a meta-analysis of recent comparative studies examining the clinical outcomes of ACL repair versus autologous tendon reconstruction. We hypothesize that modern ACL repair is non-inferior to reconstruction in terms of clinical outcomes.
Method
This meta-analysis adhered to the PRISMA guidelines [7]. The study protocol was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO) (registration ID: CRD42024574832).
Search strategy
Two authors independently searched PubMed, Cochrane Library, and Web of Science for studies published between 1 January 2015 and 27 June 2025. The search strategy combined the following terms: ((Anterior Cruciate Ligament) OR (ACL)) AND (((((Repair) OR (suture)) OR (dynamic intraligamentary stabilization)) OR (internal brace)) OR (bridge-enhanced)).The search was restricted to English-language publications. To ensure comprehensiveness, reference lists of relevant systematic reviews and included studies were manually screened. Discrepancies in study selection were resolved through consensus between the two authors.
Inclusion and exclusion criteria
Inclusion Criteria: Study types: Randomised controlled trials (RCTs), cohort studies, or case-control studies. Focus: Comparative evaluation of novel primary ACL repair techniques versus autologous tendon reconstruction.Outcome reporting: At least two of the following clinical outcomes must be documented: Failure rate, Hardware removal rate, Anteroposterior (AP) knee laxity, International Knee Documentation Committee (IKDC) score [8],Lysholm score [9],Tegner score [10].Minimum follow-up duration: 1 year.Exclusion Criteria: Non-clinical studies (e.g., in vitro or animal experiments).Inaccessible full-text articles.Duplicate patient cohorts or studies reporting the shortest follow-up duration within overlapping datasets.Studies involving multi-ligament injuries or revision ACL surgeries were excluded.
Data extraction
Two researchers independently extracted data from the included studies. The extracted information comprised: Study Characteristics: Article title, primary author, and publication year.Study design, level of evidence, and surgical repair techniques employed.Patient demographics: cohort size, sex distribution, age, follow-up duration, ligament injury site, and time from injury to surgery.Clinical Outcomes: failure rates, revision rates, hardware removal rates and knee joint laxity (anteroposterior assessment).Patient-reported outcomes: IKDC score, Lysholm score, and Tegner score.
Quality assessment
The risk of bias in RCTs, cohort studies, and case-control trials was assessed using the Cochrane Risk of Bias Tool [11] and the Newcastle-Ottawa Scale (NOS) [12]. Disagreements between authors were resolved through discussion; unresolved discrepancies were adjudicated by the senior author (SL).
Cochrane Risk of Bias Tool: This tool evaluates seven domains: (1) Random sequence generation; (2) Allocation concealment; (3) Blinding of participants and personnel; (4) Blinding of outcome assessment; (5) Incomplete outcome data; (6) Selective reporting;
(7)Other potential biases.Studies were categorised as low-risk, high-risk, or unclear-risk for each domain.NOS: The NOS assesses non-randomised studies across three categories: Selection of study groups (4 items, maximum 4 points); Comparability of groups (1 item, maximum 2 points); Outcome assessment (3 items, maximum 3 points).Total scores range from 0 to 9, with higher scores indicating lower bias risk.
Statistical analysis
Statistical analyses were performed using RevMan 5.4. Weighted mean differences (WMDs), pooled odds ratios (ORs), and their corresponding 95% confidence intervals (CIs) were calculated to evaluate outcomes. A P-value < 0.05 was considered statistically significant. Heterogeneity was assessed using the I² statistic: values < 50% indicated low heterogeneity, and a fixed-effects model was applied; values ≥ 50% prompted use of a random-effects model. Pooled effect estimates were weighted by the inverse variance method. Sensitivity analyses were performed by excluding single studies sequentially to assess robustness.Subgroup analyses were conducted for: Time from injury to surgery、injury location、study design and repair technique. A P-value of less than 0.05 was considered to indicate statistically significant differences between subgroups [13].Publication bias was evaluated via funnel plots for outcomes with ≥ 10 studies.Asymmetry in funnel plots suggested potential publication bias.
GRADE evidence assessment
The quality of evidence for primary outcomes was evaluated using the GRADE framework [14]. Two reviewers independently assessed five domains: Risk of bias: Using Cochrane Risk of Bias Tool for RCTs and NOS for observational studies.Inconsistency: I² ≥ 50% or subgroup P < 0.05.Indirectness: Clinical/methodological heterogeneity.Imprecision: 95% CIs crossing clinical thresholds (OR > 1.5 or WMD > Minimal Clinically Important Difference).Publication bias: Funnel plot asymmetry.Initial evidence levels were assigned as: RCTs: High, Observational studies: Low, Final ratings were categorized: High (⨁⨁⨁⨁),Moderate (⨁⨁⨁◯),Low (⨁⨁◯◯),Very low (⨁◯◯◯).Subgroup analyses informed assessments of inconsistency/indirectness. Disagreements were resolved by consensus.
Results
Literature search outcomes
Two independent researchers conducted a systematic search of PubMed, Web of Science, and the Cochrane Library using predefined keywords. Initial screening identified 7,408 articles. After removing 3,054 duplicates, 4,354 articles underwent title and abstract review. Of these, 4,325 were excluded based on inclusion/exclusion criteria (Fig. 1). Ultimately, 14 studies [15–28] were included:4 RCTs [17, 19, 22, 23],8 cohort studies [8, 20, 21, 24–28], 2 case-control studies [15, 16].
Fig. 1.
Flow diagram illustrating the literature search and screening process
Quality Assessment of Included Studies: The methodological quality of the RCTs was evaluated using Review Manager 5.4. A summary and graphical representation of the risk of bias for the four RCTs are presented in Figs. 2 and 3, respectively. For non-randomised studies, the NOS was employed to assess bias risk, as illustrated in Table 1.
Fig. 2.
Risk of bias summary graph for included RCTs
Fig. 3.
Risk of Bias Summary for Included RCTs
Table 1.
Risk of Bias in Non-Randomised controlled trials assessed using the NOS
Research and patient characteristics
The meta-analysis included 14 studies (14 trials; n = 908 patients), with 460 patients allocated to the repair group and 448 to the reconstruction group. All studies were published in English-language journals between 2017 and 2024. The mean patient age ranged from 17.7 to 43.2 years, with follow-up durations spanning 12–60 months. In the repair cohort, the mean time from injury to surgery was 15.2–68.4 days. Repair techniques were categorised as follows: SAR: 3 studies [15, 27, 28],IBLA: 4 studies [20, 24–26], BEAR: 2 studies [18, 19], DIS: 5 studies [16, 17, 21–23].Detailed baseline characteristics are summarised in Table 2.
Table 2.
Baseline patient characteristics
Patient distribution by repair technique: DIS (n=165), IBLA (n=136), BEAR (n=75), SAR (n=84)
DIS Dynamic Intraligamentary Stabilisation, BEAR Bridge-Enhanced ACL Repair, IBLA Internal Brace Ligament Augmentation, SAR Suture Anchor Repair, LOE level of evidence, RCT, randomised controlled trial, PCS prospective cohort study, RCS retrospective cohort study, M/F male/female, NA unavailable
Clinical outcomes
Failure rate
Failure was defined as either re-rupture of the ACL or subjective knee instability following surgery. Twelve studies reported postoperative failures, with 47/391 cases in the ACL repair group and 20/377 cases in the reconstruction group. A statistically significant difference in failure rates was observed between groups (OR: 2.24; 95% CI: 1.30–3.86; I² = 0%; P = 0.004; Fig. 4). The failure rate was significantly higher in the repair group compared to the reconstruction group.
Fig. 4.
Forest plot of postoperative failure rates
Revision rate and hardware removal rate
Nine studies reported postoperative revision rates, with 56/335 cases in the repair group and 25/308 in the reconstruction group. A statistically significant difference was observed between groups (OR: 2.01; 95% CI: 1.21–3.33; I² = 0%; P = 0.007; Fig. 5A), with the repair group exhibiting a significantly higher revision rate.Four studies documented postoperative hardware removal rates, with 26/207 cases in the repair group and 3/193 in the reconstruction group. The repair group demonstrated a markedly higher hardware removal rate (OR: 8.19; 95% CI: 2.89–23.20; I² = 0%; P < 0.001; Fig. 5B).The elevated hardware removal in repair groups (particularly DIS) may relate to implant prominence or soft-tissue irritation from high-tension devices.
Fig. 5.
Forest plots of revision rate and hardware removal rate. A: Forest plot of revision rate. B: Forest plot of hardware removal rate
AP knee laxity.
Ten studies assessed postoperative knee joint laxity in the surgical cohort. The reconstruction group demonstrated superior outcomes compared to the repair group, with a statistically significant difference (WMD: 0.30; 95% CI: 0.06–0.53; I² = 46%; P = 0.01; Fig. 6).
Fig. 6.
Forest plot of postoperative knee joint laxity
Subjective rating of patient reports
Ten studies reported IKDC scores, including 323 patients in the ACL repair group and 306 in the reconstruction group. No significant difference was observed in postoperative IKDC scores between groups (WMD: 1.31; 95% CI: −0.01 to 2.63; I² = 2%; P = 0.05; Fig. 7A).Six studies assessed Tegner activity scores, with 192 patients in the repair group and 200 in the reconstruction group. Postoperative Tegner scores showed no significant difference between groups (WMD: 0.01; 95% CI: −0.28 to 0.30; I² = 0%; P = 0.94; Fig. 7B).Six studies evaluated Lysholm knee scores, comprising 135 patients in the repair group and 157 in the reconstruction group. Postoperative Lysholm scores were significantly lower in the repair group compared to the reconstruction group (WMD: 1.62; 95% CI: 0.35–2.89; I² = 0%; P = 0.01; Fig. 7C).
Fig. 7.
Forest plots of patient-reported outcome measures. A: IKDC score; B: Tegner activity score; C: Lysholm knee score
Subgroup analysis
Given the limited number of studies, we performed subgroup analyses on the three primary outcome measures: postoperative failure rates, anterior knee instability, and IKDC scores. Subgroup analyses were conducted across three categories: time from injury to surgery, Injury location, study design, and surgical technique. The pooled subgroup analysis results are presented in Table 3. Subgroup analyses have not revealed significant between-group differences (all P > 0.05), though insufficient sample sizes in certain subgroups may mask true effects.
Table 3.
Subgroup analyses of graft failure rates, AP knee laxity, and IKDC scores
Publication bias
Publication bias was assessed for outcomes with ≥ 10 included studies. Funnel plots were generated for three outcomes: IKDC score, failure rate, and AP knee laxity. No significant publication bias was detected for IKDC scores (P = 0.22) or failure rates (P = 0.15; Fig. 8A, B). However, asymmetry in the funnel plot for AP knee laxity suggested potential publication bias (P = 0.03; Fig. 8C).
Fig. 8.
Funnel plots assessing publication bias. A: IKDC score; B: Failure rate; C: AP knee laxity
GRADE assessment of evidence quality
The GRADE assessment revealed predominantly low to very low-quality evidence across outcomes (Table 4): Failure Rate: Moderate (⨁⨁⨁◯) (downgraded for observational bias); Revision Rate: Very low (⨁◯◯◯) (bias, imprecision, non-acute repairs ↑ risk); AP Laxity: Very low (⨁◯◯◯) (bias, inconsistency [DIS technique: WMD = 0.41, P = 0.02], publication bias); IKDC Scores: Moderate (⨁⨁⨁◯) (minimal bias, precise estimates); Lysholm/Tegner Scores: Low to Very low (⨁⨁◯◯/⨁◯◯◯) (bias/imprecision).
Table 4.
GRADE assessment of evidence quality
Discussion
This meta-analysis systematically evaluated the clinical efficacy of ACL repair versus reconstruction, incorporating 14 studies (908 patients). The results indicate that despite theoretical advantages of modern repair techniques, such as preserving native proprioception and being less invasive, their overall clinical outcomes have not yet reached the level of traditional reconstruction. Significant disparities are evident in key metrics, including failure rate, revision rate, and implant removal rate. The repair group demonstrated significantly higher rates of failure, revision, and implant removal compared to the reconstruction group, a finding consistent with recent expert consensus (Zhang et al., 2025) [29].
The elevated failure rate in the repair group may be attributable to the technique’s developmental stage, the associated learning curve effect, and the relatively younger age and higher activity levels observed in the repair cohorts across included studies. The significantly higher implant removal rate in the repair group is primarily driven by the substantial proportion (36%, 165/460 cases) utilizing the DIS, whose high-tension spring screw is more prone to complications like soft tissue irritation or prominence [30].
Regarding patient-reported outcomes, no significant differences were observed between repair and reconstruction groups for the IKDC subjective score and Tegner activity level score. This aligns with the theoretical advantage of repair potentially preserving mechanoreceptors within the native ligament. However, the repair group had significantly lower Lysholm scores. This discrepancy is speculated to stem from the Lysholm scale’s high sensitivity to mechanical symptoms like instability and pain during simulated activities of daily living [9].
Subgroup analyses revealed that within the four included high-quality RCTs, repair and reconstruction demonstrated comparable clinical outcomes. In contrast, non-randomized studies showed a clear disadvantage for repair. This stark contrast strongly suggests that under strictly controlled conditions (as in RCTs), repair has the potential to achieve outcomes equivalent to reconstruction. Subgroup analysis based on time from injury to surgery confirmed superior outcomes with repair performed acutely (typically defined as < 21 days post-injury). After subgroup analysis based on tear location, the BEAR technique achieved comparable outcomes to ACL reconstruction in terms of subjective scores and arthrometric outcomes when treating mid-substance ACL tears. However, current evidence is insufficient to demonstrate that the BEAR technique significantly improves tissue healing in the repair of these mid-substance tears.While heterogeneity was observed among different surgical techniques in the technique-based subgroup analysis, the limited number of studies for specific procedures precluded statistically significant inter-group differences.
Historically, the high failure rates of early ACL repair were not only limited by primitive arthroscopic techniques but also significantly influenced by suboptimal patient selection criteria [6]. Contemporary evidence clearly establishes that repair is most effective for acute, proximal avulsion injuries. Sherman et al. [31] demonstrated significantly superior outcomes for proximal tears compared to mid-substance tears based on tear location classification. Age is also a crucial prognostic factor: Vermeijden et al. [32] reported higher failure rates in younger patients (< 25 years), likely associated with greater postoperative activity demands. Recent studies further suggest that return-to-sport patterns impact outcomes: amateur football players undergoing repair achieved a 78% return-to-play rate within 2 years, but those participating in pivoting/cutting sports maintained a higher re-injury risk, emphasizing the need for sport-specific postoperative guidance and risk management, particularly for young athletes [33]. In summary, stringent patient selection is paramount for enhancing ACL repair success. Ideal candidates should be > 25 years old, have moderate activity demands, present with an acute proximal avulsion injury confirmed by MRI (Sherman Type I/II), and place a high value on postoperative restoration of native knee proprioception.
Limitations: Only 29% (4/14) of the included studies were RCTs, with the main body of evidence derived from observational studies carrying inherent risks of selection bias. Furthermore, several studies inadequately adjusted for or reported the influence of important confounders such as age and activity level. Notably, distinct repair techniques differ in principle and expected stability. However, the limited number of studies available for each specific technique precluded a sufficiently powered subgroup comparison, hindering a deeper exploration of the relative merits of individual methods. Postoperative rehabilitation protocols are critical for functional recovery after ACL repair and should differ in principle from those for reconstruction, requiring a high degree of individualization. Nevertheless, there is a current lack of RCTs specifically comparing different rehabilitation protocols for repair versus reconstruction, and standardized guidelines are not yet established. This undoubtedly contributes to inter-study heterogeneity and may confound outcome comparisons.
Conclusion
In strictly selected patient populations (acute proximal tears, age > 25 years, moderate activity demands), ACL repair presents a viable alternative to reconstruction. However, the relatively higher failure rates and implant-related complications observed with current techniques necessitate prudent clinical decision-making.
Supplementary Information
Acknowledgements
This work has received funding from the Natural Science Foundation of Xinjiang Uygur Autonomous Region (TSYC202301B077).
We sincerely thank the Department of Sports Medicine at the Sixth Affiliated Hospital of Xinjiang Medical University for their assistance.
Authors’ contributions
Literature search and data inclusion were completed by ZHC and ZYT. ZHC was responsible for writing the article, WHS and N participated in the research design and conducted statistical analysis, TB assisted in statistical analysis, and SL was responsible for final quality control and resolving differences. All authors have read and approved the final manuscript.
Funding
This study is supported by the “Tianshan Talents” Medical and Health High level Talent Training Program (Project Number: TSYC202301B077).
Data availability
Due to privacy concerns, the data is not publicly available, but can be obtained from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
not applicable.
Consent for publication
not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Hongcheng Zheng and Yongtao Zeng contributed equally to this work.
References
- 1.Sanders TL, Maradit Kremers H, Bryan AJ, et al. Incidence of anterior cruciate ligament tears and reconstruction: A 21-Year Population-Based study. Am J Sports Med. 2016;44(6):1502–7. 10.1177/0363546516629944. [DOI] [PubMed] [Google Scholar]
- 2.Gee MSM, Peterson CDR, Zhou ML, Bottoni CR. Anterior cruciate ligament repair: historical perspective, indications, techniques, and outcomes. J Am Acad Orthop Surg. 2020;28(23):963–71. 10.5435/JAAOS-D-20-00077. [DOI] [PubMed] [Google Scholar]
- 3.Sanders TL, Pareek A, Hewett TE, et al. Long-term rate of graft failure after ACL reconstruction: a geographic population cohort analysis. Knee Surg Sports Traumatol Arthrosc. 2017;25(1):222–8. 10.1007/s00167-016-4275-y. [DOI] [PubMed] [Google Scholar]
- 4.Praz C, Kandhari VK, Saithna A, Sonnery-Cottet B. ACL rupture in the immediate build-up to the olympic games: return to elite alpine ski competition 5 months after injury and ACL repair. BMJ Case Rep. 2019;12(3):e227735. 10.1136/bcr-2018-227735. Published 2019 Mar 15. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Hughes JD, Lawton CD, Nawabi DH, Pearle AD, Musahl V. Anterior cruciate ligament repair: the current status. J Bone Joint Surg Am. 2020;102(21):1900–15. 10.2106/JBJS.20.00509. [DOI] [PubMed] [Google Scholar]
- 6.van der List JP, DiFelice GS. Primary repair of the anterior cruciate ligament: A paradigm shift. Surgeon. 2017;15(3):161–8. 10.1016/j.surge.2016.09.006. [DOI] [PubMed] [Google Scholar]
- 7.Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. 10.1136/bmj.n71. Published 2021 Mar 29. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Ebrahimzadeh MH, Makhmalbaf H, Golhasani-Keshtan F, Rabani S, Birjandinejad A. The international knee Documentation committee (IKDC) subjective short form: a validity and reliability study. Knee Surg Sports Traumatol Arthrosc. 2015;23(11):3163–7. 10.1007/s00167-014-3107-1. [DOI] [PubMed] [Google Scholar]
- 9.Briggs KK, Lysholm J, Tegner Y, Rodkey WG, Kocher MS, Steadman JR. The reliability, validity, and responsiveness of the Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee: 25 years later. Am J Sports Med. 2009;37(5):890–7. 10.1177/0363546508330143. [DOI] [PubMed] [Google Scholar]
- 10.Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med. 1982;10(3):150–4. 10.1177/036354658201000306. [DOI] [PubMed] [Google Scholar]
- 11.Higgins JP, Altman DG, Gøtzsche PC et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928. 10.1136/bmj.d5928. Published 2011 Oct 18. [DOI] [PMC free article] [PubMed]
- 12.Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25(9):603–5. 10.1007/s10654-010-9491-z. [DOI] [PubMed] [Google Scholar]
- 13.Richardson M, Garner P, Donegan S. Interpretation of subgroup analyses in systematic reviews: a tutorial. Clin Epidemiol Global Health. 2019;7(2):192–8. 10.1016/j.cegh.2018.05.005. [Google Scholar]
- 14.Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924–6. 10.1136/bmj.39489.470347.AD. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Achtnich A, Herbst E, Forkel P, et al. Acute proximal anterior cruciate ligament tears: outcomes after arthroscopic suture anchor repair versus anatomic Single-Bundle reconstruction. Arthroscopy. 2016;32(12):2562–9. 10.1016/j.arthro.2016.04.031. [DOI] [PubMed] [Google Scholar]
- 16.Bieri KS, Scholz SM, Kohl S, Aghayev E, Staub LP. Dynamic intraligamentary stabilization versus conventional ACL reconstruction: A matched study on return to work. Injury. 2017;48(6):1243–8. 10.1016/j.injury.2017.03.004. [DOI] [PubMed] [Google Scholar]
- 17.Schliemann B, Glasbrenner J, Rosenbaum D, et al. Changes in gait pattern and early functional results after ACL repair are comparable to those of ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2018;26(2):374–80. 10.1007/s00167-017-4618-3. [DOI] [PubMed] [Google Scholar]
- 18.Murray MM, Kalish LA, Fleming BC et al. Bridge-Enhanced Anterior Cruciate Ligament Repair: Two-Year Results of a First-in-Human Study. Orthop J Sports Med. 2019;7(3):2325967118824356. 10.1177/2325967118824356. Published 2019 Mar 22. [DOI] [PMC free article] [PubMed]
- 19.Murray MM, Fleming BC, Badger GJ, et al. 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):1305–15. 10.1177/0363546520913532. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Szwedowski D, Paczesny Ł, Zabrzyński J, et al. 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. 10.3390/jcm10173948. Published 2021 Aug 31. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Ferreira A, Saithna A, Carrozzo A, et al. 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):3522–32. 10.1177/03635465221126171. [DOI] [PubMed] [Google Scholar]
- 22.Glasbrenner J, Raschke MJ, Kittl C, et al. Comparable instrumented knee joint laxity and Patient-Reported outcomes after ACL repair with dynamic intraligamentary stabilization or ACL reconstruction: 5-Year results of a randomized controlled trial. Am J Sports Med. 2022;50(12):3256–64. 10.1177/03635465221117777. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Hoogeslag RAG, Huis In ‘t Veld R, Brouwer RW, de Graaff F, Verdonschot N. Acute anterior cruciate ligament rupture: repair or reconstruction?? Five-Year results of a randomized controlled clinical trial. Am J Sports Med. 2022;50(7):1779–87. 10.1177/03635465221090527. [DOI] [PubMed] [Google Scholar]
- 24.Kayaalp ME, Sürücü S, Çerçi MH, Aydın M, Mahiroğulları M. Anterior cruciate ligament repair using dynamic intraligamentary stabilization provides a similarly successful outcome as all-inside anterior cruciate ligament reconstruction with a faster psychological recovery in moderately active patients. Jt Dis Relat Surg. 2022;33(2):406–13. 10.52312/jdrs.2022.631. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Duong JKH, Bolton C, Murphy GT, Fritsch BA. Anterior cruciate ligament repair versus reconstruction: A clinical, MRI and patient-reported outcome comparison. Knee. 2023;45:100–9. 10.1016/j.knee.2023.09.008. [DOI] [PubMed] [Google Scholar]
- 26.Müller S, Bühl L, Nüesch C, Pagenstert G, Mündermann A, Egloff C. 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):3131–41. 10.1177/03635465231194784. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Ciceklidag M, Kaya I, Ayanoglu T, et al. Proprioception after primary repair of the anterior cruciate ligament. Am J Sports Med. 2024;52(5):1199–208. 10.1177/03635465241228839. [DOI] [PubMed] [Google Scholar]
- 28.Simard SG, Greenfield CJ, Khoury AN. Anterior cruciate ligament repair with suture tape augmentation of proximal tears and early anterior cruciate ligament reconstruction with suture tape augmentation result in comparable clinical outcomes with anterior cruciate ligament reconstruction at 2-Year Follow-Up. Arthrosc. 10.1016/j.arthro.2024.07.021. Published Online July 26, 2024. [DOI] [PubMed]
- 29.Zhang S, Xia T, Dai X et al. Primary repair of proximal anterior cruciate ligament injury: a global expert consensus statement. Burns Trauma. 2025;13:tkae079. 10.1093/burnst/tkae079. Published 2025 May 24. [DOI] [PMC free article] [PubMed]
- 30.Opoku M, Fang M, Lu W, Li Y, Xiao W. Acute anterior cruciate ligament rupture: can repair become an alternative to reconstruction: a meta-analysis of randomized controlled trials and cohort studies. J Orthop Surg Res. 2024;19(1):331. 10.1186/s13018-024-04812-x. Published 2024 Jun 2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Sherman MF, Lieber L, Bonamo JR, Podesta L, Reiter I. The long-term followup of primary anterior cruciate ligament repair. Defining a rationale for augmentation. Am J Sports Med. 1991;19(3):243–55. 10.1177/036354659101900307. [DOI] [PubMed] [Google Scholar]
- 32.Vermeijden HD, Yang XA, van der List JP, DiFelice GS. Role of age on success of arthroscopic primary repair of proximal anterior cruciate ligament tears. Arthroscopy. 2021;37(4):1194–201. 10.1016/j.arthro.2020.11.024. [DOI] [PubMed] [Google Scholar]
- 33.Annibaldi A, Monaco E, Carrozzo A, Caiolo V, Criseo N, Cantagalli MR, Ferretti A, Maffulli N. Return to soccer after acute anterior cruciate ligament primary repair: A 2-Year minimum Follow-up study of 50 amateur players. Am J Sports Med. 2024;52(9):2237–43. 10.1177/03635465241256099. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Due to privacy concerns, the data is not publicly available, but can be obtained from the corresponding author upon reasonable request.