Primary Anterior Cruciate Ligament Repair for Acute Proximal Tears Shows High Return to Sport and a 10% Failure Rate at a Minimum 2‐Year Follow‐Up

Purpose To evaluate the clinical outcomes after arthroscopic primary anterior cruciate ligament (ACL) repair, with and without lateral extra‐articular procedures, at a minimum of 2 years follow‐up. Methods A retrospective case series of prospectively collected data was conducted on patients operated between 2018 and 2023. Consecutive patients with acute proximal ACL tears underwent arthroscopic primary repair within 15 days of injury when intraoperative reducibility and good tissue quality (Sherman I‐II) were confirmed. Patients with anterolateral lesions or high‐risk received a concomitant lateral extra‐articular procedure (anterolateral structure repair, Segond fixation, or Coker‐Arnold tenodesis). Outcomes included International Knee Documentation Committee subjective score, Lysholm score, Knee injury and Osteoarthritis Outcome Score, ACL‐return to sports after injury score, Forgotten Joint Score‐12, Tegner, and side‐to‐side laxity; analyses assessed group comparisons and associations with failure and return to sport (RTS). Results Of 123 patients receiving ACL primary repair, 120 completed the 24 months‐minimum follow‐up (mean 47.9 ± 12.8 months; range 25‐82). The overall failure rate was 10%. Among the 106 patients treated with combined ACL primary repair and a lateral extra‐articular procedure, 9 (8.5%) experienced failure. Patients who had ACL repair failure were significantly younger (mean age, 22.3 vs 32.9) and more active. RTS was achieved in 95.4% of patients excluding failures, with 79.6% returning to preinjury or higher Tegner activity scale levels. Successful RTS was associated with older age, lower side‐to‐side laxity, and higher ACL‐return to sports after injury and Knee injury and Osteoarthritis Outcome‐Sport scores. Regarding patient‐reported outcome measures, 69.6% achieved patient‐acceptable symptom state for International Knee Documentation Committee, 84.8% for ACL‐return to sports after injury, and 69.6% for Forgotten Joint Score‐12. The mean side‐to‐side laxity was 1.6 ± 1.2 mm. The secondary surgery rate (excluding failures) was 11.6%, with most involving contralateral ACL injuries. Conclusions Arthroscopic primary ACL repair led to high RTS rates, 10% failure rate, and satisfactory patient‐reported outcome measures at a minimum 2‐year follow‐up. Outcomes were significantly influenced by age and activity level, with higher failure risk in younger and more active patients. Level of Evidence Level IV, retrospective case series.