Suture-augmented primary anterior cruciate ligament repair with internal brace shows acceptable re-rupture rates, favourable outcomes and high return-to-sport rates: A systematic review.

Purpose: To describe the safety, efficacy and clinical outcomes of suture-augmented primary anterior cruciate ligament (ACL) repair with internal bracing. Methods: A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines; the protocol was registered in the PROSPERO database (registration number: CRD42024573962). A comprehensive search of the PubMed, Embase and Cochrane Library databases up to August 2024 was conducted to identify studies reporting clinical outcomes of suture-augmented ACL repair. Inclusion criteria were a minimum follow-up of 2 years, reporting of re-rupture rates together with complications, or functional outcome scores such as International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm or Tegner activity scale. Results: Thirteen studies involving 671 patients met the eligibility criteria and were included. The ACL re-rupture rate was 10.6% (95% confidence interval [CI]: 7.4-14.2), and the rate of reoperations unrelated to ACL re-rupture (primarily for hardware removal) was 3.2% (95% CI: 0.9-6.5). The pooled data showed a mean time to reinjury of 1.2 years (95% CI: 1-1.3), and failure occurred at a mean patient age of 19.8 years (95% CI: 14.8-24.8). The mean return to sport was 9.5 months (95% CI: 5.7-13.3). Patient-reported outcome measures included IKDC with a post-operative mean score of 86.9 (95% CI: 83.6-90.1) and KOOS total score of 85 (95% CI: 82.1-88). KT-1000 laxity measurements revealed a mean side-to-side difference of 0.9 mm (95% CI: 0.5-1.3). Conclusion: Suture-augmented primary ACL repair with internal brace shows acceptable clinical results, encouraging functional recovery and re-rupture rates. Internal bracing is not associated with a high rate of complications, suggesting that the technique is safe and appropriate for use in carefully selected patients. However, heterogeneity in the existing studies means that additional high-quality, long-term comparative studies are needed to clarify the indications and reliability of this procedure. Level of Evidence: Level IV, systematic review of studies with LoE I-IV.