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Large variation in indications, preferred surgical technique and rehabilitation protocol for primary anterior cruciate ligament repair: a survey among ESSKA members

Abstract

Purpose

To assess current surgical preferences and practice patterns regarding primary anterior cruciate ligament (ACL) repair among European Society for Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA) members.

Methods

A web-based survey was designed, including questions regarding indications for primary repair, outcomes of primary repair, and rehabilitation protocols. An invitation for study participation was sent by email to all ESSKA e-mail contacts. Descriptive statistics were performed.

Results

A total of 169 surgeons responded to the survey (7% response rate of active members). Lack of supporting scientific evidence is the main reason for not using repair as a surgical treatment (63%). Most important indications were proximal avulsion tears (84%), younger age (49%), and older age (34%). Among those currently utilizing repair as a treatment option, transosseous tunnel fixation repair (34%) and repair with internal brace using transosseous tunnel fixation (32%) were the most preferred techniques. Eleven percent indicated dynamic intraligamentary stabilization as their preferred technique. A similar rate of progression for rehabilitation for repair and reconstruction techniques was noted among respondents.

Conclusion

This practice survey shows that the majority of surgeons indicated the main reason for not incorporating primary repair in their current practices was a lack of supporting scientific evidence. Among those holding favourable attitudes and beliefs, most surgeons indicated patients with proximal tears, younger-aged, and older-aged patients might be eligible for repair. Prospective studies with higher levels of evidence are warranted to establish guidelines for repair, including indications, optimal surgical technique, and rehabilitation protocols.

Level of evidence

V (expert opinion).

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Funding

No funding has been received for this study.

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Correspondence to Gregory S. DiFelice.

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GSD declares he is a paid consultant and receives research grants from Arthrex (Naples, FL, USA).

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Appendix 1: Current surgical preferences and practice patterns regarding primary ACL repair among ESSKA members

Appendix 1: Current surgical preferences and practice patterns regarding primary ACL repair among ESSKA members

This survey assesses the current surgical preferences and current practice among ESSKA members regarding anterior cruciate ligament (ACL) treatment and specifically ACL repair. The main focus of this survey is to assess the indications for ACL repair, the current or future technique for ACL repair and rehabilitation following primary repair. The objective is to get a better understanding of the current practice patterns on primary ACL repair and identify the experience of ESSKA members on this technique.

1. General information

  • 1A. What is your primary practice setting?

    1. o

      Academic institution

    2. o

      Hospital group

    3. o

      Mixed academic institution and private practice

    4. o

      Private practice

  • 1B. How many ACL injuries do you see in your clinic annually?

    1. o

       < 50

    2. o

      50–100

    3. o

      100–200

    4. o

       > 200

  • 1C. How many ACL surgeries do you perform annually?

    1. o

      0–25

    2. o

      25–50

    3. o

      50–100

    4. o

       > 100

  • 1D. What is your preferred timing of surgery in order to achieve the highest functional outcome?

    1. o

       < 2 weeks after injury

    2. o

      2–6 weeks after injury

    3. o

      6 weeks–3 months after injury

    4. o

      3–6 months after injury

    5. o

       > 12 months after injury

    6. o

      No preference

2. Indications of primary ACL repair

  • 2A. Do you think there is a role for primary ACL repair in carefully selected patients?

    1. o

      No

    2. o

      Yes

  • 2B. If yes, which patients are eligible for primary ACL repair in your practice (please mark all that apply)?

    1. o

      All patients

    2. o

      Young patients (< 18 years of age)

    3. o

      Older patients (> 30 years of age)

    4. o

      Proximal avulsion tears

    5. o

      Midsubstance tears

    6. o

      Distal tears

    7. o

      Mild osteoarthritis

    8. o

      Low activity level (Tegner 5–6)

    9. o

      Multiligamentous knee injuries

  • 2C. If not, what is the main reason for not incorporating primary ACL repair in your practice?

    1. o

      Negative historical outcomes

    2. o

      Repaired ACL is not strong enough

    3. o

      Lack of scientific evidence to support primary ACL repair

    4. o

      Satisfaction with reconstruction outcomes

  • 2D. What would be your preferred surgical technique for ACL repair?

    1. o

      Transosseous repair

    2. o

      Suture anchor repair

    3. o

      Repair and internal brace using buttons

    4. o

      Repair and internal brace using suture augmentation

    5. o

      Ligamys (Dynamic Intraligamentary Stabilization)

3. Primary ACL repair


  • 3A. Do you currently utilize primary repair as a treatment option for ACL injuries in your practice?

    1. o

      Yes

    2. o

      No (if not, please go to question 4)

  • 3B. How many open ACL repairs have you performed?

    1. o

      0

    2. o

      1–10

    3. o

      11–20

    4. o

      21–40

    5. o

      40–60

    6. o

      60–100

    7. o

       > 100

  • 3B. How many arthroscopic ACL repairs have you performed?

    1. o

      0

    2. o

      1–10

    3. o

      10–20

    4. o

      20–40

    5. o

      40–60

    6. o

      60–100

    7. o

       > 100

  • 3C. What is your preferred surgical technique?

    1. o

      Transosseous repair

    2. o

      Suture anchor repair

    3. o

      Repair with an internal brace/suture augmentation using buttons

    4. o

      Repair with an internal brace/suture augmentation using anchors

    5. o

      Ligamys (DIS)

    6. o

      Bride-enhanced ACL repair

    7. o

      Other

  • 3D. What percentage of patients who receive ACL surgery do you perform a primary repair on?

    1. o

       < 10%

    2. o

      10–20%

    3. o

      20–40%

    4. o

      40–60%

    5. o

       > 60%

  • 3E. What is the failure/reinjury rate in your own clinical experience?

    1. o

       < 2%

    2. o

      2–5%

    3. o

      5–10%

    4. o

      10–15%

    5. o

      15–25%

    6. o

      25–35%

    7. o

       > 35%

  • 3F. In your clinical experience, what is the most common reason for failure following repair?

    1. o

      New trauma

    2. o

      Fixation failure

    3. o

      Stretching of the repaired ligament

    4. o

      Too rapid rehabilitation progression

    5. o

      Other,—

  • 3G. In your practice, do you find that patients are more satisfied after repair vs. reconstruction?

    1. o

      Primary repair

    2. o

      Reconstruction

    3. o

      No difference

4. Rehabilitation


  • 4A. Do you have a standard rehabilitation program for patients following reconstruction?

    1. o

      Yes

    2. o

      No

  • 4B. If you perform ACL repair, does the rehabilitation program differ from reconstruction (if so, please describe)?

    1. o

      Yes —

    2. o

      No

  • 4C. If so, is the speed of the rehabilitation protocol different between repair and reconstruction?

    1. o

      Rehabilitation following repair is advanced more quickly than following reconstruction

    2. o

      No difference between both treatments

    3. o

      Rehabilitation following repair is advanced more slowly than following reconstruction

  • 4C. What are your main success criteria after surgical treatment (please select all that apply)?

    1. o

      Absence of giving way

    2. o

      Return to preinjury sports participation

    3. o

      Quadriceps and hamstring strength > 90% of the uninvolved leg

    4. o

      Patient Reported Outcomes

    5. o

      Satisfied patient

    6. o

      Other—

5. Comments


  • 5A. Please share any other comments you have below:

    1. o

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Vermeijden, H.D., Yang, X.A., van der List, J.P. et al. Large variation in indications, preferred surgical technique and rehabilitation protocol for primary anterior cruciate ligament repair: a survey among ESSKA members. Knee Surg Sports Traumatol Arthrosc 28, 3613–3621 (2020). https://doi.org/10.1007/s00167-020-06011-7

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Keywords

  • Anterior cruciate ligament
  • Primary repair
  • Preferences
  • Technique
  • Rehabilitation
  • Survey