Alessandro Annibaldi

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.

Purpose: To compare MRI-based graft maturation and tibial tunnel behavior in all-inside anterior cruciate ligament (ACL) reconstruction using either a quadrupled semitendinosus (ST4) graft or a standard doubled semitendinosus–gracilis (DSTG) technique and to assess mid-term clinical outcomes. Materials and methods: This is a single-center prospective comparative cohort with sequential, non-randomized allocation. Primary imaging endpoints were graft signal-to-noise quotient (SNQ, PD-FS) and tibial tunnel cross-sectional area (CSA) change; clinical endpoints included PROMs and laxity at ≥ 24 months. Reliability was assessed with two independent evaluators and reported using ICC (two-way random, absolute agreement) with 95% CIs. Results: Forty patients ( n = 20 per group) completed MRI at 12 months and clinical follow-up at 24 months. SNQ was similar between groups (ST4 1.94 [95% CI 1.28–2.60] vs DSTG 2.84 [1.93–3.75]; difference − 0.90 [− 1.99 to 0.19], P = 0.39). Tibial tunnel widening was lower with ST4 (45.5% [23.7–67.3]) versus DSTG (106.7% [78.3–135.1]); difference − 61.2% [− 95.8 to − 26.6]; P = .02. PROMs and laxity were comparable. Conclusions: AI-ST4 and DSTG ACL reconstruction demonstrated similar graft maturation at 12 months, with less tibial tunnel widening after AI-ST4. At 24 months, clinical outcomes were equivalent between groups; although SNQ and tibial tunnel CSA demonstrated good reproducibility, these imaging differences were not demonstrably associated with functional superiority.

Background: Lateral extra-articular tenodesis (LET) combined with anterior cruciate ligament reconstruction (ACLR) has been shown to reduce graft failure. While the benefits of techniques such as the modified Lemaire procedure and anterolateral ligament reconstruction are well documented, the literature on other LET techniques is more limited. Purpose: To evaluate the clinical outcomes and risk factors for failure in patients undergoing ACLR combined with LET using the Coker-Arnold modification of the MacIntosh technique. Study Design: Case series; Level of evidence, 4. Methods: This retrospective case series included patients who underwent primary ACLR using a hamstring tendon autograft along with concurrent LET at a single institution between 2013 and 2022. Clinical evaluations included subjective outcome measures (International Knee Documentation Committee [IKDC] score, Knee Injury and Osteoarthritis Outcome Score [KOOS], Lysholm score, and Tegner score) and objective KT-1000 arthrometer testing. Risk factors for graft failure were identified using multivariate logistic regression. Results: The final study cohort consisted of 328 patients. At a mean follow-up of 72.4 ± 30.3 months, 11 patients (3.4%) experienced graft failure. The mean side-to-side difference according to the KT-1000 arthrometer was 1.45 ± 1.04 mm. Patients showed excellent outcomes, with 91.5% achieving the patient acceptable symptom state (PASS) for the IKDC score and >90.0% achieving the PASS for all KOOS subscales, except for the Activities of Daily Living subscale (79.6%). High Tegner scores (≥8) and the presence of chondral lesions were independently associated with graft failure (odds ratio, 6.82 and 5.89, respectively; P < .01). Age, sex, pivot-shift grade, meniscal status, and timing of surgery were not predictive of failure. Conclusion: Combined ACLR and LET using the Coker-Arnold modification of the MacIntosh technique led to a 3.4% failure rate at a mean follow-up of >5 years. Higher Tegner scores and the presence of chondral lesions were found to be independently associated with reruptures.

Purpose: To compare return to sport (RTS), time to RTS, postoperative activity levels, failure rates and anterior laxity between anterior cruciate ligament (ACL) repair and reconstruction (ACLR) through a systematic review and meta‐analysis of comparative studies. Methods: A systematic literature search was performed in November 2024 across PubMed, MEDLINE, Scopus and Google Scholar following PRISMA guidelines. Studies comparing ACL repair and reconstruction with a minimum 24‐month follow‐up and reporting RTS outcomes were included. Data on RTS rates and timing, Tegner Activity Score (TAS), ACL‐Return to Sport after Injury scale (ACL‐RSI), anterior tibial translation and failure rates were extracted. Meta‐analyses were conducted using Review Manager (RevMan) 5.4. Odds ratios (ORs) and mean differences (MDs) were calculated using fixed or random‐effects models based on heterogeneity. Results: Nine studies (two randomized controlled trials [RCTs] and seven cohort studies), including 819 patients (352 repairs and 467 reconstructions), met the inclusion criteria. The RTS rate was significantly higher in the ACL repair group (75.3%) than in the ACLR group (66.5%) (OR 0.61; 95% confidence interval [CI]: 0.42–0.88; p = 0.009; I ² = 0%). Time to RTS was 1.38 months shorter for ACL repair (MD –1.38; 95% CI: –1.76 to –1.00; p < 0.00001; I ² = 73%). No significant differences were found in postoperative TAS or anterior laxity. However, ACL repair had a higher failure rate (9.8% vs. 3.3%; OR 4.00; 95% CI: 2.41–6.63; p = 0.0001; I ² = 60%). ACL‐RSI scores were slightly higher after reconstruction (MD 3.96; 95% CI: 0.49–7.44; p = 0.03; I ² = 79%). Conclusion: Modern ACL repair results in a statistically significant earlier RTS compared to ACLR. However, this difference must be correlated with its clinical relevance, as postoperative activity levels and anterior knee laxity are similar between the two procedures. In addition, the risk of failure is approximately four times higher after ACL repair, and psychological readiness may be superior after ACLR. Level of Evidence: Level III.