Beyond repair versus reconstruction: the need to compare contemporary anterior cruciate ligament-preserving strategies

Contemporary anterior cruciate ligament (ACL)-preserving strategies, including bridge-enhanced ACL restoration (BEAR), dynamic intra-ligamentary stabilization (DIS), and internal brace ligament augmentation (IBLA), have renewed interest in native ACL preservation as an alternative to ACL reconstruction (ACLR) in carefully selected patients.Although these procedures are often collectively referred to as ACL repair, they represent biologically and mechanically distinct treatment strategies, each with different indications and eligibility criteria.Previous comparative studies and meta-analyses have largely evaluated individual techniques or collectively analyzed ACL-preserving procedures in comparison with ACLR, leaving their relative effectiveness insufficiently established.Moreover, differences in tear location, tissue quality, surgical timing, patient age, activity level, and repairability may compromise the transitivity required for valid indirect comparisons.Therefore, future studies should determine whether existing evidence forms a sufficiently connected and clinically comparable treatment network before attempting to rank BEAR, DIS, IBLA, and ACLR.Direct randomized comparisons among similar patient populations remain the preferred approach.If network connectivity and transitivity can be demonstrated, network meta-analysis may complement these trials by identifying comparative treatment effects and remaining evidence gaps.The primary objective should not be to establish a universally superior ACL procedure, but rather to determine the most appropriate ACL-preserving strategy for each injury pattern and individual patient.