Skeletal Radiology

, Volume 47, Issue 5, pp 619–629 | Cite as

Arthroscopic primary repair of the anterior cruciate ligament: what the radiologist needs to know

  • Steven P. Daniels
  • Jelle P. van der List
  • J. Jacob Kazam
  • Gregory S. DiFelice
Review Article


Recently, there has been a renewed interest in primary repair of proximal anterior cruciate ligament (ACL) tears. Magnetic resonance imaging (MRI) plays an important role in preoperative patient selection and in postoperative ligament assessment. Knowledge of the imaging factors that make patients candidates for primary ACL repair, namely proximal tear location and good tissue quality, can help radiologists provide information that is meaningful for surgical decision making. Furthermore, an understanding of the surgical techniques can prevent misinterpretation of the postoperative MRI. This article reviews preoperative MRI characterization of ACL injuries, techniques of arthroscopic primary ACL repair surgery and examples of postoperative MRI findings.


Magnetic resonance imaging Anterior cruciate ligament tear Arthroscopy 


Compliance with ethical standards

Conflict of interest

The senior author is a paid consultant for Arthrex and receives research support from Arthrex.

The other authors have no disclosures.


  1. 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.CrossRefPubMedGoogle Scholar
  2. 2.
    Hawkins RJ, Misamore GW, Merritt TR. Followup of the acute nonoperated isolated anterior cruciate ligament tear. Am J Sports Med. 1984;14(3):205–10.CrossRefGoogle Scholar
  3. 3.
    Sanders TL, Pareek A, Kremers HM, et al. Long-term follow-up of isolated ACL tears treated without ligament reconstruction. Knee Surgery, Sport Traumatol Arthrosc. 2016:1–8.Google Scholar
  4. 4.
    Kruse LM, Gray B, Wright RW. Rehabilitation after anterior cruciate ligament reconstruction: a systematic review. J Bone Joint Surg Am. 2012;94(19):1737–48.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Finsterbush A, Frankl U, Matan Y, Mann G. Secondary damage to the knee after isolated injury of the anterior cruciate ligament. Am J Sports Med. 1990;18(5):475–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Davarinos N, O’Neill BJ, Curtin W. A brief history of anterior cruciate ligament reconstruction. Adv Orthop Surg. 2014;2014:1–6.CrossRefGoogle Scholar
  7. 7.
    Murrell G, Maddali S, Horovitz L, Oakley SP, Warren RF. The effects of time course after anterior cruciate ligament injury in correlation with meniscal and cartilage loss. Am J Sports Med. 2001;29(1):9–14.CrossRefPubMedGoogle Scholar
  8. 8.
    Robson A. Ruptured cruciate ligaments and their repair by operation. Ann Surg. 1903;37(5):716–8.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Warren RF. Primary repair of the anterior cruciate ligament. Clin Orthop Relat Res. 1983;172:65–70.Google Scholar
  10. 10.
    Marshall JL, Warren RF, Wickiewicz TL. Primary surgical treatment of anterior cruciate ligament lesions. Am J Sports Med. 1982;10(2):103–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Sherman MF, Bonamo JR. Primary repair of the anterior cruciate ligament. Clin Sports Med. 1988;7(4):739–50.PubMedGoogle Scholar
  12. 12.
    Feagin JAJ, Curl WW. Isolated tear of the anterior cruciate ligament: 5-year follow-up study. Am J Sports Med. 1976;4(3):95–100.CrossRefPubMedGoogle Scholar
  13. 13.
    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.CrossRefPubMedGoogle Scholar
  14. 14.
    Engebretsen L, Benum P, Sundalsvoll S. Primary suture of the anterior cruciate ligament: a 6-year follow-up of 74 cases. Acta Orthop Scand. 1989;60(5):561–4.CrossRefPubMedGoogle Scholar
  15. 15.
    Harilainen A, Myllynen P. Treatment of fresh tears of the anterior cruciate ligament: a comparison of primary suture and augmentation with carbon fibre. Injury. 1987;18(6):396–400.CrossRefPubMedGoogle Scholar
  16. 16.
    Jones KG. Results of use of the central one-third of the patellar ligament to compensate for anterior cruciate ligament deficiency. Clin Orthop Relat Res. 1980;147:39–44.Google Scholar
  17. 17.
    Hefti F, Gachter A, Jenny H, Morscher E. Replacement of the anterior cruciate ligament: a comparative study of four different methods of reconstruction. Arch Orthop Trauma Surg. 1982;100(2):83–94.CrossRefPubMedGoogle Scholar
  18. 18.
    van der List JP, DiFelice GS. Role of tear location on outcomes of open primary repair of the anterior cruciate ligament: a systematic review of historical studies. Knee. 2017;24(5):898–908.Google Scholar
  19. 19.
    van der List JP, DiFelice GS. Preservation of the anterior cruciate ligament: a treatment algorithm based on tear location and tissue quality. Am J Orthop (Belle Mead NJ). 2016;45(7):E393–405.Google Scholar
  20. 20.
    Taylor SA, Khair MM, Roberts TR, DiFelice GS. Primary repair of the anterior cruciate ligament: a systematic review. Arthroscopy. 2015;31(11):2233–47.CrossRefPubMedGoogle Scholar
  21. 21.
    van Eck CF, Limpisvasti O, ElAttrache NS. Is there a role for internal bracing and repair of the anterior cruciate ligament? A systematic literature review. Am J Sports Med [Internet]. 2017.
  22. 22.
    van der List JP, DiFelice GS. Primary repair of the anterior cruciate ligament: a paradigm shift. Surgeon. 2017;15(3):161–8.CrossRefPubMedGoogle Scholar
  23. 23.
    DiFelice GS, Villegas C, Taylor S. Anterior cruciate ligament preservation: early results of a novel arthroscopic technique for suture anchor primary anterior cruciate ligament repair. Arthroscopy. 2015;31(11):2162–71.CrossRefPubMedGoogle Scholar
  24. 24.
    van der List JP, Mintz DN, DiFelice GS. The location of anterior cruciate ligament tears: a prevalence study using magnetic resonance imaging. Orthop J Sport Med. 2017;5(6).
  25. 25.
    van der List JP, DiFelice GS. Preservation of the anterior cruciate ligament: surgical techniques. Am J Orthop (Belle Mead NJ). 2016;45(7):E406–14.Google Scholar
  26. 26.
    Anthony IC, Mackay G. Anterior cruciate ligament repair revisited. Preliminary results of primary repair with internal brace ligament augmentation: a case series. Orthop Muscular Syst. 2015;4(2).
  27. 27.
    DiFelice GS, van der List JP. Arthroscopic primary repair of proximal anterior cruciate ligament tears. Arthrosc Tech. 2016;5(5):e1057–61.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    van der List J, DiFelice G. Arthroscopic primary repair of proximal anterior Cruciate ligament tears: no deterioration at mid-term follow-up. Arthrosc J Arthrosc Relat Surg [Internet]. 2017;33(6):e7.
  29. 29.
    Tibor L, Chan PH, Funahashi TT, Wyatt R, Maletis GB, Inacio MCS. Surgical technique trends in primary ACL reconstruction from 2007 to 2014. J Bone Joint Surg Am. 2016;98(13):1079–89.CrossRefPubMedGoogle Scholar
  30. 30.
    Samuelsen BT, Webster KE, Johnson NR, Hewett TE, Krych AJ. Hamstring autograft versus patellar tendon autograft for ACL reconstruction: is there a difference in graft failure rate? a meta-analysis of 47,613 patients. Clin Orthop Relat Res. 2017;475(10):2459–68.Google Scholar
  31. 31.
    Gabler CM, Jacobs CA, Howard JS, Mattacola CG, Johnson DL. Comparison of graft failure rate between autografts placed via an anatomic anterior cruciate ligament reconstruction technique: a systematic review, meta-analysis, and meta-regression. Am J Sports Med. 2016;44(4):1069–79.CrossRefPubMedGoogle Scholar
  32. 32.
    Irarrázaval S, Kurosaka M, Cohen M, Fu FH. Anterior cruciate ligament reconstruction. J ISAKOS Jt Disord Orthop Sport Med. 2016;1(1):38–52.CrossRefGoogle Scholar
  33. 33.
    van Eck CF, Lesniak BP, Schreiber VM, Fu FH. Anatomic single- and double-bundle anterior cruciate ligament reconstruction flowchart. Arthroscopy. 2010;26(2):258–68.CrossRefPubMedGoogle Scholar
  34. 34.
    Sajovic M, Vengust V, Komadina R, Tavcar R, Skaza K. A prospective, randomized comparison of semitendinosus and gracilis tendon versus patellar tendon autografts for anterior cruciate ligament reconstruction: five-year follow-up. Am J Sports Med. 2006;34(12):1933–40.CrossRefPubMedGoogle Scholar
  35. 35.
    Beaufils P, Gaudot F, Drain O, Boisrenoult P, Pujol N. Mini-invasive technique for bone patellar tendon bone harvesting: its superiority in reducing anterior knee pain following ACL reconstruction. Curr Rev Musculoskelet Med. 2011;4(2):45–51.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Kartus J, Magnusson L, Stener S, Brandsson S, Eriksson BI, Karlsson J. Complications following arthroscopic anterior cruciate ligament reconstruction: a 2–5-year follow-up of 604 patients with special emphasis on anterior knee pain. Knee Surgery, Sport Traumatol Arthrosc. 1999;7(1):2–8.CrossRefGoogle Scholar
  37. 37.
    Wittstein JR, Wilson JB, Moorman CT III. Complications related to hamstring tendon harvest. Oper Tech Sports Med. 2017;14(1):15–9.CrossRefGoogle Scholar
  38. 38.
    Kaeding CC, Aros B, Pedroza A, Pifel E, Amendola A, Andrish JT, et al. Allograft versus autograft anterior cruciate ligament reconstruction: predictors of failure from a MOON prospective longitudinal cohort. Sports Health. 2010;3(1):73–81.CrossRefGoogle Scholar
  39. 39.
    Kaiser J, Vignos MF, Liu F, Kijowski R, Thelen DG. MRI assessments of cartilage mechanics, morphology and composition following reconstruction of the anterior cruciate ligament. Clin Biomech. 2016;34:38–44.CrossRefGoogle Scholar
  40. 40.
    Imhauser C, Mauro C, Choi D, et al. Abnormal tibiofemoral contact stress and its association with altered kinematics after center-center anterior cruciate ligament reconstruction: an in vitro study. Am J Sports Med. 2013;41(4):815–25.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Simon D, Mascarenhas R, Saltzman BM, Rollins M, Bach BR, MacDonald P. The relationship between anterior cruciate ligament injury and osteoarthritis of the knee. Adv Orthop [Internet]. 2015.
  42. 42.
    Song E-K, Seon J-K, Yim J-H, Woo S-H, Seo H-Y, Lee K-B. Progression of osteoarthritis after double- and single-bundle anterior cruciate ligament reconstruction. Am J Sports Med. 2013;41(10):1–7.CrossRefGoogle Scholar
  43. 43.
    Cheatham SA, Johnson DL. Anticipating problems unique to revision ACL surgery. Sports Med Arthrosc. 2013;21(2):129–34.CrossRefPubMedGoogle Scholar
  44. 44.
    Maak TG, Voos JE, Wickiewicz TL, Warren RF. Tunnel widening in revision anterior cruciate ligament reconstruction. J Am Acad Orthop Surg. 2010;18(11):695–706.CrossRefPubMedGoogle Scholar
  45. 45.
    Kamath GV, Redfern JC, Greis PE, Burks RT. Revision anterior cruciate ligament reconstruction. Am J Sports Med. 2010;39(1):199–217.CrossRefPubMedGoogle Scholar
  46. 46.
    Wright RW, Gill CS, Chen L, et al. Outcome of revision anterior cruciate ligament reconstruction: a systematic review. J Bone Joint Surg Am. 2012;94(6):531–6.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Andriolo L, Filardo G, Kon E, et al. Revision anterior cruciate ligament reconstruction: clinical outcome and evidence for return to sport. Knee Surg Sport Traumatol Arthrosc. 2015;23(10):2825–45.CrossRefGoogle Scholar
  48. 48.
    Grassi A, Ardern CL, Muccioli G, Neri MP, Marcacci M, Zaffagnini S. Does revision ACL reconstruction measure up to primary surgery ? A meta-analysis comparing outcomes and radiographic results. Br J Sports Med. 2016;50:716–24.CrossRefPubMedGoogle Scholar
  49. 49.
    Fleming BC, Carey JL, Spindler KP, Murray MM. Can suture repair of ACL transection restore normal anteroposterior laxity of the knee? An ex vivo study. J Orthop Res. 2008;26(11):1500–5.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Murray MM, Fleming BC. Use of a bioactive scaffold to stimulate anterior cruciate ligament healing also minimizes posttraumatic osteoarthritis after surgery. Am J Sports Med. 2013;41(8):1762–70.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Murray MM. Current status and potential for primary ACL repair. Clin Sports Med. 2009;28(1):51–61.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Gao F, Zhou J, He C, et al. A morphologic and quantitative study of mechanoreceptors in the remnant stump of the human anterior cruciate ligament. Arthroscopy. 2016;32(2):273–80.CrossRefPubMedGoogle Scholar
  53. 53.
    van der List JP, DiFelice GS. Range of motion and complications following primary repair versus reconstruction of the anterior cruciate ligament. Knee. 2017;24(4):798–807.CrossRefPubMedGoogle Scholar
  54. 54.
    Boden BP, Dean GS, Feagin JAJ, Garrett WEJ. Mechanisms of anterior cruciate ligament injury. Orthopedics. 2000;23(6):573–8.PubMedGoogle Scholar
  55. 55.
    Heard WMR, VanSice WC, Savoie FH 3rd. Anterior cruciate ligament tears for the primary care sports physician: what to know on the field and in the office. Phys Sports Med. 2015;43(4):432–9.CrossRefGoogle Scholar
  56. 56.
    Spindler KP, Wright RW. Anterior cruciate ligament tear. N Engl J Med. 2008;359(20):2135–42.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Huang W, Zhang Y, Yao Z, Ma L. Clinical examination of anterior cruciate ligament rupture: a systematic review and meta-analysis. Acta Orthop Traumatol Turc. 2016;50(1):22–31.PubMedGoogle Scholar
  58. 58.
    Smith C, McGarvey C, Harb Z, et al. Diagnostic efficacy of 3-T MRI for knee injuries using arthroscopy as a reference standard: a meta-analysis. Am J Roentgenol. 2016;207(2):369–77.CrossRefGoogle Scholar
  59. 59.
    van der List JP, DiFelice GS. The role of ligament repair in anterior cruciate ligament surgery. In: Mascarenhas R, Bhatia S, Lowe WR, editors. Ligamentous injuries of the knee, 1st ed. Houston: Nova Science Publishing; 2016. p. 199–220.Google Scholar
  60. 60.
    van der List JP, DiFelice GS. Preoperative magnetic resonance imaging predicts eligibility for arthroscopic primary anterior cruciate ligament repair. Knee Surg Sport Traumatol Arthrosc. 2017.
  61. 61.
    Pereira ER, Ryu KN, Ahn JM, Kayser F, Bielecki D, Resnick D. Evaluation of the anterior cruciate ligament of the knee: comparison between partial flexion true sagittal and extension sagittal oblique positions during MR imaging. Clin Radiol. 1998;53(8):574–8.CrossRefPubMedGoogle Scholar
  62. 62.
    Ng WHA, Griffith JF, Hung EHY, Paunipagar B, Law BKY, Yung PSH. Imaging of the anterior cruciate ligament. World J Orthop. 2011;2(8):75–84.CrossRefPubMedPubMedCentralGoogle Scholar
  63. 63.
    Van Dyck P, Vanhoenacker FM, Gielen JL, et al. Three tesla magnetic resonance imaging of the anterior cruciate ligament of the knee: can we differentiate complete from partial tears? Skelet Radiol. 2011;40(6):701–7.CrossRefGoogle Scholar
  64. 64.
    Van Dyck P, Vanhoenacker FM, Lambrecht V, et al. Prospective comparison of 1.5 and 3.0-T MRI for evaluating the knee menisci and ACL. J Bone Joint Surg Am. 2013;95(10):916–24.CrossRefPubMedGoogle Scholar
  65. 65.
    Van Dyck P, de Smet E, Veryser J, et al. Partial tear of the anterior cruciate ligament of the knee: injury patterns on MR imaging. Knee Surg Sport Traumatol Arthrosc. 2012;20(2):256–61.CrossRefGoogle Scholar
  66. 66.
    Kosaka M, Nakase J, Toratani T, et al. Oblique coronal and oblique sagittal MRI for diagnosis of anterior cruciate ligament tears and evaluation of anterior cruciate ligament remnant tissue. Knee. 2017;21(1):54–7.CrossRefGoogle Scholar
  67. 67.
    Crain EH, Fithian DC, Paxton EW, Luetzow WF. Variation in anterior cruciate ligament scar pattern: does the scar pattern affect anterior laxity in anterior cruciate ligament-deficient knees? Arthroscopy. 2005;21(1):19–24.CrossRefPubMedGoogle Scholar
  68. 68.
    van der List JP, DiFelice GS. Successful arthroscopic primary repair of a chronic anterior cruciate ligament tear 11 years following injury. HSS J. 2017;13(1):90–5.CrossRefPubMedGoogle Scholar
  69. 69.
    Wiggins AJ, Grandhi RK, Schneider DK, Stanfield D, Webster KE, Myer GD. Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Am J Sports Med. 2016;44(7):1861–76.CrossRefPubMedPubMedCentralGoogle Scholar
  70. 70.
    Webster KE, Feller JA. Exploring the high reinjury rate in younger patients undergoing anterior cruciate ligament reconstruction. Am J Sports Med. 2016;44(11):2827–32.CrossRefPubMedGoogle Scholar
  71. 71.
    Allen MM, Pareek A, Krych AJ, et al. Are female soccer players at an increased risk of second anterior cruciate ligament injury compared with their athletic peers? Am J Sports Med. 2016;44(10):2492–8.CrossRefPubMedGoogle Scholar
  72. 72.
    Larruskain J, Lekue JA, Diaz N, Odriozola A, Gil SM. A comparison of injuries in elite male and female football players: a 5-season prospective study. Scand J Med Sci Sports. 2017.
  73. 73.
    Mackay GM, Blyth MJG, Anthony I, Hopper GP, Ribbans WJ. A review of ligament augmentation with the internal brace. Surg Technol Int. 2015;26:239–55.PubMedGoogle Scholar
  74. 74.
    Bencardino JT, Beltran J, Feldman MI, Rose DJ. MR imaging of complications of anterior cruciate ligament graft reconstruction. Radiographics. 2009;29(7):2115–26.CrossRefPubMedGoogle Scholar
  75. 75.
    Casagranda BC, Maxwell NJ, Kavanagh EC, Towers JD, Shen W, Fu FH. Normal appearance and complications of double-bundle and selective-bundle anterior cruciate ligament reconstructions using optimal MRI techniques. Am J Roentgenol. 2009;192(5):1407–15.CrossRefGoogle Scholar
  76. 76.
    Meyers AB, Haims AH, Menn K, Moukaddam H. Imaging of anterior cruciate ligament repair and its complications. Am J Roentgenol. 2010;194(2):476–84.CrossRefGoogle Scholar
  77. 77.
    Ferretti M, Ekdahl M, Shen W, Fu FH. Osseous landmarks of the femoral attachment of the anterior cruciate ligament: an anatomic study. Arthroscopy. 2007;23(11):1218–25.CrossRefPubMedGoogle Scholar
  78. 78.
    Edwards A, Bull AMJ, Amis AA. The attachments of the anteromedial and posterolateral fibre bundles of the anterior cruciate ligament : part 2: femoral attachment. Knee Surg Sport Traumatol Arthrosc. 2008;16(1):29–36.CrossRefGoogle Scholar
  79. 79.
    Śmigielski R, Zdanowicz U, Drwięga M, Ciszek B, Williams A. The anatomy of the anterior cruciate ligament and its relevance to the technique of reconstruction. Bone Joint J. 2016;98–B(8):1020–6.CrossRefPubMedGoogle Scholar
  80. 80.
    Nawabi DH, Tucker S, Schafer KA, et al. ACL fibers near the lateral intercondylar ridge are the most load bearing during stability examinations and isometric through passive flexion. Am J Sports Med. 2016;44(10):1–9.CrossRefGoogle Scholar
  81. 81.
    Claes S, Verdonk P, Forsyth R, Bellemans J. The “ligamentization” process in anterior cruciate ligament reconstruction: what happens to the human graft? A systematic review of the literature. Am J Sports Med. 2011;39(11):2476–83.CrossRefPubMedGoogle Scholar
  82. 82.
    Pauzenberger L, Syré S, Schurz M. “Ligamentization” in hamstring tendon grafts after anterior cruciate ligament reconstruction: a systematic review of the literature and a glimpse into the future. Arthroscopy. 2013;29(10):1712–21.CrossRefPubMedGoogle Scholar

Copyright information

© ISS 2017

Authors and Affiliations

  • Steven P. Daniels
    • 1
  • Jelle P. van der List
    • 2
  • J. Jacob Kazam
    • 1
  • Gregory S. DiFelice
    • 2
  1. 1.Department of RadiologyNew York Presbyterian Hospital-Weill Cornell Medical CenterNew YorkUSA
  2. 2.Orthopedic Trauma and Sports Medicine ServicesHospital for Special SurgeryNew YorkUSA

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