Bridge-Enhanced Anterior Cruciate Ligament Repair versus Autograft Reconstruction in Anterior Cruciate Ligament Surgery.

INTRODUCTION

Surgical repair of the anterior cruciate ligament (ACL) using an autograft is the accepted standard treatment for symptomatic ACL tears, but morbidity associated with the harvest of the autograft, residual laxity, and the possibility of a second injury and post-traumatic osteoarthritis have brought about renewed interest in biologic repair. Bridge-enhanced ACL repair (BEAR) employs an extracellular matrix, resorbable implant, and autologous blood to promote healing of the native ligament.

MATERIALS AND

METHODS

The PubMed, Embase, Cochrane Library, and Scopus databases were queried for English-language papers from January 2019 until June 2026, with a selection of landmark papers in translation retained. The highest priority evidence included randomized trials, prospective cohort studies, registries, systematic reviews, consensus statements, and mechanistic animal studies. The narrative synthesis was conducted in line with the SANRA principles.

RESULTS

BEAR is supported by a prospective randomized trial demonstrating noninferior 2-year score and instrumented anteroposterior laxity versus autograft reconstruction, and higher hamstring strength with a higher number of ipsilateral second ACL surgeries (numerically) in BEAR. There are small or short-term early registry results and 6-year first-in-human data that are encouraging. Autograft reconstruction is versatile in all patterns, chronic injuries, revision scenarios, and high-risk athletes. Bone-patellar tendon-bone autograft may have a lower revision risk for young pivoting athletes. At the same time, hamstring harvest may result in lower strength, and a smaller autograft may result in a higher failure risk.

CONCLUSION

BEAR should be used as a selective repair option for patients with acute and repairable ACL tears, and good tibial stump and tissue quality. The indication is unclear, chronicity is long, the risk of instability is high, or revision predictability is high, and the autograft reconstruction is preferred.