Arthroscopic Primary Repair and Suture Augmentation for Combined Acute Femoral and Tibial Attachment Avulsion of Anterior Cruciate Ligament

OBJECTIVE: Combined acute femoral- and tibial-side avulsion injuries of the anterior cruciate ligament (ACL) are rare and present a distinct surgical challenge because both attachment sites require restoration while preserving the native ligament tissue. This study aimed to describe an arthroscopic ACL primary repair (ACLPR) technique with suture augmentation for the treatment of rare combined acute femoral- and tibial-side ACL avulsion injuries and to present its short-term clinical outcome. METHODS: A 21-year-old male patient sustained a twisting injury to his right knee while landing during a basketball game 3 weeks before presentation. He subsequently developed right knee pain and recurrent episodes of giving way and was diagnosed with combined acute femoral- and tibial-side ACL avulsion tears. An arthroscopic ACLPR technique reinforced with suture augmentation was performed. The procedure involved in situ suture capture of both avulsed ACL ends using circumferential cinch-loop sutures. Femoral fixation was achieved with a polyetheretherketone (PEEK) anchor, while tibial fixation was performed through bone tunnels. A suture augmentation was incorporated to provide secondary stabilization and protect the repair during early healing. A transtibial pullout repair was performed to repair the lateral meniscus posterior root tear through a separate tibial tunnel. The surgical technique, including multi-tunnel orientation, precise suture management, and secure extracortical fixation, is described in a step-by-step manner. RESULTS: The technique allowed for anatomical reapproximation of the native ACL and stable fixation of both avulsion sites while minimizing graft harvest morbidity and optimizing biological healing conditions. At the 1-year follow-up, satisfactory clinical outcomes were observed, with restoration of knee stability and function, and no major complications reported. CONCLUSION: Arthroscopic primary repair with suture augmentation is an optional approach for combined acute femoral and tibial attachment avulsion of the ACL.