Editorial Commentary: Primary Anterior Cruciate Ligament Repair Is Back-But Younger Age Remains a Risk Factor: Defining the Who, When, and How.

Abstract

Primary anterior cruciate ligament (ACL) repair has re-emerged as a compelling alternative to reconstruction, fueled by advances in surgical techniques, biologic understanding, and renewed interest in tissue preservation. Yet, despite encouraging modern outcomes, fundamental questions remain regarding patient selection, surgical timing, and adjunctive procedures. Several case series and noncomparative studies show high return-to-sport rates and acceptable short-term survivorship following primary ACL repair in carefully selected patients with acute proximal tears. In the majority of studies, patients with proximal ACL tears who are candidates for primary ACL repair are expeditiously treated surgically to mitigate tissue degeneration. Although these findings highlight the potential viability of repair in contemporary practice, they also underscore critical nuances including strict inclusion criteria, the influence of age and activity level on failure risk, and the confounding role of augmentative procedures that limit broad generalization. As enthusiasm for repair continues to grow, surgeons must balance innovation with caution, recognizing that success appears highly dependent on the "who, when, and how" of surgical decision-making. Ultimately, primary ACL repair may represent a valuable option for select patients, but defining its precise role within modern ACL treatment algorithms remains an evolving challenge.