As the necessity of ACL reconstruction was questioned in the following decades and long-term results showed deterioration, orthopedic surgeons abandoned the technique of suturing the ACL and turned to reconstruction. Initially, good results were reported but could not be maintained over time. Robson in 1895, treating a miner with ACL and posterior cruciate ligament (PCL) rupture using primary open suture. Knowledge about the function of the ACL and the possible consequences in case of a rupture were obtained much later. This frequent injury has been well-known since ancient times, first described by Galen over 2000 years ago. The number of injuries of the anterior cruciate ligament (ACL) requiring surgery in the United States is reported to be between 80,000 and 200,000 per year and steadily increasing. Nevertheless, this technique provides an inferior ultimate failure load compared to graft techniques, so a careful rehabilitation program must be followed if using this technique in vivo. By establishing an arthroscopic technique in which proximal ACL avulsion can be reattached, the original ACL can be preserved by using a knotless anchor and a threefold suture configuration. However, with the latest improvements in surgical techniques, instrumentation, hardware and imaging, primary ACL suture repair might be a treatment option for a select group of patients. Clinical relevance: Since primary suture repair techniques of ACL tears have been abandoned because of inconsistent results, ACL reconstruction remains the gold standard of treating ACL tears. Within this construct, no failure at the bone–anchor interface was seen. Conclusions: The results of this in vitro study show that when performing ACL suture using a knotless anchor, a modified Kessler–Bunnell suture provides superior biomechanical properties than a single and a twofold suture. In cyclic loading, there was no significant difference noted for the different configurations in terms of stiffness and elongation. Comparing the different configurations, the modified Kessler–Bunnell suture showed significant superior ultimate failure load, with 81, 2 N ± 15, 6 N compared to the twofold and single sutures (50, 5 N ± 14 N and 37, 5 ± 3, 8 N). Results: The ultimate failure load of the knotless anchor was 198, 76 N ± 23, 4 N significantly higher than all of the tested ACL suture configurations. Using a material testing machine, the structural properties were evaluated for cyclic loading followed by loading to failure. Then, three different suture configurations were evaluated to reattach the remaining ACL. First, in 10 porcine femora, the biomechanical properties of the knotless anchor, without the ligament attached, were tested. Methods: In this study, 35 fresh-frozen porcine knees underwent proximal ACL refixation. The purpose of this study is to compare the biomechanical properties of different suture configurations using a knotless anchor. Therefore, we investigated a refixation technique for acute primary proximal ACL repair. Purpose: Several suture techniques have been described in the past for direct ACL repair with poor healing capacity and a high re-rupture rate.
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