From the Guidelines
Ligament suture is rarely indicated for Grade 3 ACL sprains in modern orthopedic practice. Direct suture repair of the ACL is generally not recommended for complete tears because it typically fails to provide adequate long-term stability, as noted in the updated clinical practice guideline summary by the American Academy of Orthopaedic Surgeons 1. This is due to the ACL's poor healing capacity related to its limited blood supply and the constant mechanical stresses it endures within the knee joint.
Instead, ACL reconstruction using autografts (typically hamstring tendon or patellar tendon) or allografts is the standard of care for Grade 3 ACL tears, particularly in active individuals. The American Academy of Orthopaedic Surgeons recommends that surgeons should consider autograft over allograft to improve patient outcomes and decrease ACL graft failure rate, particularly in young and/or active patients, based on strong evidence 1.
Some key points to consider in the management of ACL injuries include:
- The use of autografts, such as bone-tendon-bone (BTB) or hamstring, to reduce the risk of graft failure or infection 1.
- The importance of reconstruction timing, with the previous guideline recommending reconstruction within 5 months of ACL injury to protect articular cartilage and menisci.
- The consideration of patient factors, such as age and activity level, in determining the best treatment approach.
The only exceptions where primary repair might be considered include very specific cases such as avulsion fractures where the ligament has pulled off with a bone fragment, proximal tears with good tissue quality, or in select pediatric patients with immature growth plates. Even in these limited scenarios, repair is often augmented with additional reinforcement techniques. The poor outcomes of isolated ACL suture repair were well-documented in previous studies, showing high failure rates and persistent instability, which led to the widespread adoption of reconstruction techniques that provide more reliable and durable results for patients with complete ACL tears.
From the Research
Ligament Suture Indications
- Ligament suture is not typically indicated for Grade 3 sprains of the Anterior Cruciate Ligament (ACL) as the primary treatment option, according to current clinical practice guidelines 2.
- The management of ACL rupture involves a combination of rehabilitation, ACL reconstruction (ACLR), and post-operative rehabilitation, with the goal of restoring knee function and preventing further injury 3.
- The treatment options for ACL rupture include:
- Rehabilitation as first-line treatment, followed by ACLR in patients who develop functional instability
- ACLR and post-operative rehabilitation as the first-line treatment
- Pre-operative rehabilitation followed by ACLR and post-operative rehabilitation 3
- Clinical practice guidelines provide recommendations for evaluating, diagnosing, and treating knee ligament injuries, including determining when patients are ready to return to activities after injury 2
Grade 3 Sprains of the ACL
- Grade 3 sprains of the ACL are considered severe injuries, characterized by complete ligament rupture and significant knee instability.
- The treatment of Grade 3 ACL sprains typically involves ACLR and post-operative rehabilitation, rather than ligament suture alone 3
- Rehabilitation plays a crucial role in the management of ACL injuries, with the goal of restoring knee function, addressing psychological barriers to activity participation, and preventing further injury 3