Background: This study compares three surgical procedures that we used in the past to treat ruptures of the anterior cruciate ligament: acute primary repair, acute repair augmented with a synthetic ligament-augmentation device, and acute repair augmented with autologous bone-patellar tendon-bone graft.

Methods: This is the third report on a group of patients who were randomized to the three different procedures between 1986 and 1988. There were fifty patients in each group. The patients were evaluated prospectively at one, two, five, and sixteen years with use of the Tegner activity score and the Lysholm functional score. Stability of the knee was assessed with clinical examination and with use of the KT-1000 arthrometer.

Results: One hundred and twenty-nine (88%) of the 147 patients who were available for follow-up completed the study. Eleven patients (24%) who had a primary repair, four patients (10%) who had repair with a ligament augmentation device, and one patient (2%) who had augmentation with autologous bone-patellar tendon-bone graft underwent anterior cruciate ligament revisions between the primary operation and the sixteen-year follow-up examination. The rate of revision was ten times higher in the group that had primary repair than in the group that had repair with bone-patellar tendon-bone graft (p = 0.003). In the remaining patients, those who had repair with a bone-patellar tendon-bone graft had significantly more stable knees than those who had repair with a ligament augmentation device, as measured by the Lachman test (p = 0.026). Nine (11%) of the eighty-five patients for whom data were available had osteoarthritis in the primarily reconstructed knee, and three patients (3.5%) had osteoarthritis in the contralateral knee at sixteen years (p = 0.001); no difference was noted among the three groups. The mean Lysholm score at sixteen years was 88 points for the knees that had primary repair, 85 points for those that had repair with the ligament augmentation device, and 90 points for those managed with a bone-patellar tendon-bone graft (p = 0.286).

Conclusions: At long-term (sixteen-year) follow-up, the rate of revision anterior cruciate ligament surgery is much higher following primary repair than after primary repair augmented by a bone-patellar tendon-bone graft. It can be expected that approximately 10% of patients undergoing anterior cruciate ligament reconstruction acutely will have osteoarthritis develop in the reconstructed knee. We no longer perform any of these surgical techniques as open procedures.

Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.