Good afternoon. As Dr. Riverola said, it's an honor for us being a guest nation in the IANA meeting, so I want to thank the board for the invitation. No, my disclosures, this is where I work. And my focus will be to see a current view of the ACL primary repair. As Dr. Carola said, we have the first studies that talk about the ACL primary open repair, and the first who described the first repair was Maya Robson in 1895 with the reattachment of the ACL and PCL, and Ivan Palmer and O'Donoghue were the others in this period that tried to do the repair. The first outcomes were good, but after a few years, the new studies showed that that outcome was not so good. So in summary, if we show the history, we can know that primary open ACL repair was the gold standard in the 70s and 80s, but the mid-term follow-up with re-raptors up to 50%, and the development of the ACL reconstruction techniques with excellent or good outcomes become to be the gold standard in the 90s. So now we have recent new studies showing the ACL repair, and we don't know now what will happen. So the first who described the type of lesion and the possibility to repair to achieve good results was German, and he did the first classification, and he told us about the good results with football players with younger age, increased pre-operatory pivot shift, and with type 2 proximal tear. He said that he had good results in younger patients, less than 22 years, skiing players, type tear 1 with good tissue, and lower grade pivot. The second study that I think was the continuity of these studies was the Geller-Van der Bisk study, that they studied the results and they found that primary repair was a reasonable treatment for patients with proximal ACL tears, and they have excellent results if they treat only proximal tears. So what was the reason to the repair to fail in the past? Well, as Carola says, we have obsolete open surgical technique, large arthrotomies, open procedure, they treat not only ACL injuries, they use prolonged positive casting mobilization, they treat all type of tears, all age of patients, and all kind of quality tissue. Why primary ACL repair is in the scenario now? If you do that technique, you don't require graft incorporation, you preserve the complex anatomy, native tissue, nerve fibers, proprioception, and native kinematics. No harvest, no tunnel adrenal, no graft donor site morbidity, no muscle weakness or anterior knee pain. So you can do a selective tear type to be repaired, you can use modern arthroscopic surgical techniques, you can use modern instrumentation and implants, and you can try to have bio-enhancements and early mobilization. All that will allow more successful results. And as they know and they show before me, we have a lot of new studies that show us that the preclinical and clinical studies can show, can achieve good results. We have new primary ACL repair techniques that the dynamic intraligamentary stabilization, the internal brace ligament augmentation, the use of anchors, and the bridge-enhanced ACL repair. And the first results of this kind of studies are really optimistic. If you see the Carola Svanek systematic review, she achieved the conclusion that maybe a role of the ACL repair in a specific subset of patients, if we have proximal tear patterns, we have better healing potential than distal or mesostatic tears. Some form of internal bracing with either no absorbable sutures, scalp or graft, can increase the success rate of the procedure. We can use PRP augmentation only when used in combination with scalpel. And better outcome in younger patients, specifically in escheletically immature, acute repairs offer better outcomes in that delay. So just think about primary ACL repair as a tool. If you have a clinical and audiological MRI confirmation of a complete isolate ACL rupture, a confirmation of a tear type, if it's possible, the best result will be with isolate acute type I, abortion of the femur, good tissue duality, young patient or escheletically immature, acute repair offers better outcome than delayed repair, modern technique may be strong enough with some form of internal bracing. So if this is really crazy, I don't know, but this area is an exciting area for research. We don't know if it's a new reality or a trend in orthopedic evolution, but early results are promising. We must need long-term results to be real optimistic or not. And the vast majority of the ACL patients are not candidates for repair, but those that are may achieve better results. Thank you very much.

ACL primary repair

classification systems

younger patients

preserving natural anatomy

better outcomes