Arthroscopic primary repair of the anterior cruciate ligament with internal brace ligament augmentation: a viable alternative to reconstruction? A systematic literature review and analysis

BACKGROUND: Primary anterior cruciate ligament (ACL) repair has re-gained significant interest due to its inherent anatomic advantages: retaining the proprioceptive fibers of the ACL may prevent kinesiophobia, while the procedure avoids donor site morbidity. Should revision become necessary, conventional ACL reconstruction remains a viable option. Research regarding this technique has accelerated, with 60.4% of the relevant literature published within the last 8 years. AIM OF THE STUDY: The most frequently reported technique is arthroscopic primary repair with internal brace ligament augmentation (IBLA). The objective of this study was to conduct a systematic review and analysis of contemporary papers, define the failure rate of the procedure, assess secondary outcomes, and identify optimal candidates for the procedure. PATIENTS AND METHODS: A systematic search of the PubMed, MEDLINE and Cochrane Library databases was conducted reported in adherence to PRISMA guidelines. The inclusion criteria encompassed English publications (Level of evidence I-IV) from the last 10 years presenting arthroscopic operations with a study population of at least 10 patients. Included studies were required to report failure rates, complication rates and patient-reported outcome measures (PROMs) or objective knee joint laxity assessments with a mean follow-up exceeding 12 months and retention rates exceeding 80%. RESULTS: Twenty-four studies, representing 866 patients, were included. The mean age at the surgery was 34.8 years, and 45.0% of the cohort was male. The mean interval from injury to surgery was 41.6 days, with a mean follow-up duration of 31.1 months. A total of 79 failures were identified, corresponding to a mean failure rate of 9.1% CI 95% [7.2;11.0] for all included patients, and 9.8% CI 95% [7.8;11.9] for followed patients (n = 804). The incidence rate of failure was 3.8% CI 95% [2.9;4.6]. CONCLUSION: Primary ACL repair with IBLA appears to be a feasible option for a well-defined patient subset. The results from contemporary studies are promising, demonstrating acceptable complication rate and excellent PROMs at mid-term follow-up, however, generalizability remains limited, consistent with the current level II–IV evidence base.