DISCUSSION

The management of femoral‐side ACL avulsions involves a critical balance between achieving mechanical stability, promoting biological healing, and preserving proprioceptive function. Unlike midsubstance tears, injuries at the femoral footprint benefit from the region's abundant vascularity, which provides a natural advantage for the biological healing of the ligament remnant. Furthermore, the native ligament is richly innervated with proprioceptive nerve endings—primarily Ruffini and Pacinian corpuscles—which are crucial for sensorimotor control of the knee and functional recovery. 7 , 14 , 15 Although traditional remnant‐preserving anatomical reconstruction represents the first‐line treatment for midsubstance ACL tears, its application in this specific subtype necessitates the resection of a substantial portion of the avulsed native ligament. This inevitably leads to the loss of proprioceptive nerve endings and compromises the inherent biological healing potential, which may ultimately result in suboptimal long‐term functional recovery for patients. In contrast, isolated ACL repair offers the distinct advantage of achieving anatomical reduction of the ligament remnant to its femoral footprint. This approach maximizes the preservation of the remnant's vascular supply and proprioceptive neural pathways. 16 , 17 Basic studies have confirmed that the preserved ligament remnant is rich in fibroblasts and vascular endothelial cells, which can regulate the local inflammatory microenvironment through paracrine signaling, thereby providing progenitor cells and nutritional support for ligament healing. Moreover, the intact preservation of proprioceptive receptors—such as Ruffini and Pacinian corpuscles—within the remnant serves as the critical anatomical foundation for maintaining precise neuromuscular control of the knee postoperatively. 18 , 19 , 20 However, extensive clinical experience has shown that the mechanical strength of the isolated repair is sufficient only for activities of daily living and cannot withstand the loads associated with high‐intensity sports. Consequently, this procedure carries a relatively high risk of re‐rupture, particularly for athletes and other young, active individuals. 21 , 22 , 23 Based on this rationale, the modified “suspender‐style” traction‐preservation and native ligament reconstruction technique proposed in this study embodies the core philosophy of “reconstruction and repair,” achieving their effective integration and thereby providing an optimized solution for the treatment of femoral‐side ACL avulsions.

The modified technique presented in this study integrates the advantages of mechanical stability, biological healing, and preserved proprioceptive function (Table 1). On one hand, the “suspender‐style” traction‐reduction strategy maximizes the retention of the native ACL tissue's biological value. During the procedure, a #5 ETHIBOND suture (Ethicon, Raritan, NJ) is used to create a lasso‐loop around the proximal one‐third of the ACL remnant. This suture is then employed via the “suspender‐style” method to achieve anatomical reduction and fixation of the remnant to its femoral footprint. This approach avoids the extensive resection of the native ligament stump required in traditional reconstruction, fully leveraging the rich vascularity of the femoral footprint to create a favorable microenvironment for native ligament healing. Concurrently, it preserves the proprioceptive nerve endings within the native ligament, which are crucial for restoring joint position sense, kinesthesia, and neuromuscular control. This preservation serves as the foundation for high‐level functional recovery and successful return to sports. On the other hand, the concomitant autologous tendon reconstruction establishes robust mechanical support. In this study, grafts prepared from the semitendinosus and gracilis tendons were used, which offer excellent biocompatibility and mechanical strength. This effectively compensates for the insufficient mechanical strength inherent in isolated repair techniques. Furthermore, the standardization of the key procedural steps is crucial for ensuring the efficacy of this technique (Table 2).

Advantages | Disadvantages
Integrates biological repair (preservation) with mechanical reconstruction | Primarily suitable for acute femoral‐side avulsions/proximal tears with viable remnants; less advantageous for chronic injuries or poor‐quality remnants
Retains the native ligament's proprioceptive nerve endings and vascular supply, enhancing healing potential and sensorimotor recovery | Absence of long‐term (e.g., 1 and 3 yrs) follow‐up studies to validate sustained efficacy
Provides robust mechanical support via autologous tendon graft, addressing the weakness of isolated repair | Current study has a small sample; requires larger, multicenter trials for broader validation
Accurate tunnel placement and ligament reduction help restore native ACL biomechanics and reduce instability risks | No direct comparison with conventional reconstruction or isolated repair in this study, limiting comparative efficacy conclusions
Favorable for active populations: particularly beneficial for young, active individuals and athletes aiming for high‐level functional return | Success depends on precise, gentle handling of the native remnant and exact tunnel positioning, requiring a learning curve
 | The preservation of the native ligament remnant on the tibial side may lead to inaccurate tibial tunnel positioning by less experienced surgeons

Pearls | Pitfalls
Suitable for Sherman type I avulsions, requiring good quality and healing potential of the ACL remnant | Not recommended for chronic ACL tears or Sherman type II and III injuries
Suture ligation of the ACL remnant should be placed at least at the proximal one‐third, ensuring even traction force for reduction | Insufficient suture purchase may lead to remnant tear or inadequate reduction and fixation
Femoral tunnel: knee flexed at 120°, positioned at the center of the ACL femoral footprint on the lateral femoral condyle Tibial tunnel: knee flexed at 90°, positioned at the center of the native ACL tibial footprint | The presence of an intact tibial ACL remnant may obscure visualization, leading to inaccurate tibial tunnel placement by less experienced surgeons
Diameter of the autologous hamstring tendon graft should ideally be between 7 and 9 mm | A diameter <7 mm may cause graft‐tunnel micromotion (windshield‐wiper effect) and tunnel widening. A diameter >9 mm may risk notch impingement or tunnel fracture
While pulling the graft into the femoral tunnel, simultaneously tension the ETHIBOND sutures (Ethicon, Raritan, NJ) to reduce the native ligament remnant to its femoral footprint | Insufficient traction or insecure suture fixation may prevent the remnant from achieving close apposition to the bone, compromising healing
Use a knot pusher to securely tie the ETHIBOND sutures (Ethicon, Raritan, NJ) to the traction sutures of the adjustable‐loop device, creating a stable “suspender‐like” suspensory fixation | Loose knots or suture slippage can lead to remnant retraction, loss of the repair effect, and potential notch impingement
The interference screw is inserted into the tibial tunnel with the graft under appropriate tension | Insufficient initial graft tension may result in postoperative laxity
The knee must be taken through a full range of motion under arthroscopy to confirm the absence of notch impingement and to assess the tension and position of both the native remnant and the graft | Failure to dynamically check for impingement may lead to graft abrasion against the intercondylar notch, causing pain, graft laxity, or failure

This study has several limitations. First, the technique is primarily indicated for patients with femoral‐side ACL avulsions or proximal midsubstance tears, provided the remnant tissue is of sufficient quality and healing potential. Its advantages diminish considerably in cases of chronic injuries or when the remnant is severely absorbed or of poor quality, where conventional reconstruction remains a more reliable option. Second, this study lacks long‐term follow‐up data. Further investigation with clinical outcomes at 1, 3, and more years postoperatively is necessary to validate the technique's long‐term efficacy. The sample size also requires expansion; future multicenter, large‐scale clinical studies are needed to better establish its generalizability. Finally, the absence of a control group (e.g., patients treated with conventional reconstruction or isolated repair) limits direct comparative analysis. Subsequent controlled studies are warranted to clarify the differences between this technique and existing procedures regarding clinical outcomes, mechanical stability, and long‐term prognosis.

The modified “suspender‐type” traction‐preservation and native ligament reconstruction technique presented in this study not only preserves the proprioceptive function and vascular advantages of the native ACL but also provides adequate mechanical strength via autologous tendon grafting, thereby establishing favorable conditions for postoperative functional recovery and return to sports. This standardized technique shows good potential for clinical adoption, offering a surgical alternative for patients with ACL Sherman type I injuries.