Pediatric ACL Repair with BEAR Implant

Direct Primary Repair

Direct repair is most applicable to proximal ACL tears (Type I and II on the Van Der List classification) — those in which the ligament has avulsed from its femoral attachment and a viable tissue stump remains. Using arthroscopic techniques, suture anchors or suspensory fixation devices are used to reattach the torn ligament end to its native footprint. Published series of direct repair for proximal ACL tears in pediatric patients show good clinical and patient-reported outcomes at short and mid-term follow-up, with the significant advantage of zero growth plate violation. Repair is generally easier and more successful within the first 6–8 weeks of injury.

Augmented Repair

Augmented repair techniques supplement the direct repair with a stabilizing device to protect the healing ligament. Internal brace augmentation using non-absorbable synthetic materials has shown high rates of re-operation and failure in adolescent patients — with re-operation rates more than 10 times higher than reconstruction in some series. For this reason, non-absorbable augmentation is generally not recommended. Temporary augmentation for approximately 3 months followed by device removal has shown more acceptable outcomes in early series and requires further study.

Bridge-Enhanced ACL Repair (BEAR Implant)

The Bridge-Enhanced ACL Repair (BEAR) technique is an innovative biologic approach currently being investigated in adult and adolescent populations. The technique uses an absorbable collagen scaffold derived from bovine tissue. This scaffold is hydrophilic and is combined with the patient’s own blood before being positioned within the intercondylar notch, where it acts as a scaffold for the torn ACL to grow back together. Sutures within the ACL stump are used to approximate the torn ends into the scaffold, encouraging biologic healing rather than tissue replacement.

In a first-in-human study comparing BEAR to primary hamstring autograft reconstruction, the technique was not inferior in terms of clinical outcomes or patient-reported scores at 2 years. The key theoretical advantage of the BEAR approach is that it prevents synovial fluid — which inhibits healing — from contacting the repair site while allowing a native collagen scaffold to guide tissue regeneration. Dr. Patel offers the BEAR implant as part of his practice’s ACL repair program. At present, its use in pediatric patients should be confined to appropriate candidates with proximal ACL tears and high-quality tissue, with rigorous follow-up.

ACL repair is not appropriate for every pediatric patient. The following factors are assessed when considering repair:

• Proximal ACL tear (Type I or II) identified on high-quality MRI — midsubstance and distal tears are not amenable to primary repair
• Good quality residual ACL stump tissue on MRI
• Presentation within an appropriate timeframe from injury (typically within 6–8 weeks)
• Absence of significant associated injuries that would compromise the repair environment

Families considering ACL repair should be counseled that this remains an evolving area with less long-term evidence compared to reconstruction, and that close follow-up is essential.