Surgery Options

Surgery Options

There are different surgical approaches and graft choices for ACL reconstruction. But the first question might be “Why have surgery at all?” Or, “Do I really need surgery.”

Core Issues Regarding ACL Surgery

The primary concern regarding considerations of ACL reconstruction is knee stability. There’s multiple structures in the knee that provide stability, including four different ligaments. During a knee injury, it may be the case that more than one structure is damaged, however, the ACL is the most common. Properly working anatomy of the knee joint is necessary for everything from simply standing up, to walking. For more active folks, we then get into running, jumping / landing, and so on. There are individuals, (athletes and otherwise), that can learn to function without an ACL at all; some of whom can perform at very hight levels. This requires a great deal of muscle strength and control to compensate for lack of ACL support. Such people might avoid activities involving pivoting, cutting and so forth, or need to learn movement adaptations and other coping mechanisms. However, not everyone can compensate. Those who can’t may develop instability, and additional damage to other knee structures. Those who can live with ACL damage on an ongoing basis may be referred to as “copers” as they can ‘cope’ with the situation, whereas other are “non-copers.”

Deciding on surgical vs. non-surgical options can be a challenging choice for some. In some cases, there may not be options if treatment is just unavailable due to financial or geography. For those with the ability to chose, it can be both a practical and emotional decision. In fact, there is sometimes apparently some degree of frustration or even anger among proponents of one path or another. This might be partially due to people – already frustrated by their injury – feeling the need to justify their own difficult choice. That emotional investment can spill over into strong opinions about what others should do, even though every case is different. There are outright arguments among proponents of one path or another. Part of the challenge is research may be inconclusive in terms of long term recovery for varying options or even in terms of diagnosis. (That is, even the wonders of modern MRIs are not always fully definitive.)

Ultimately, the decision around ACL surgery involves a mix of medical judgment, personal values, lifestyle goals, and access to resources. It’s important to approach the topic with humility and openness, recognizing that what works for one person may not be right for another, and that uncertainty is often part of the process.

Surgical vs. Non-Surgical Treatment

Not all ACL injuries require surgery. The decision depends on several factors including age, activity level, occupation, presence of associated injuries, and degree of knee instability. Generally, surgery is recommended for:

• Young, active individuals
• Athletes who wish to return to pivoting sports
• Patients with significant instability in daily activities
• Cases with associated repairable meniscal tears

Again, surgery vs. not can apparently be a somewhat contentious or even controversial issue for some. In the end, everyone has to choose their own path. This site is focused on the surgical option. However, there are lots of resources out there, (websites, support groups, etc.), for those who choose a non-surgical route to recovery. There are those who believe non-surgical, (or at least “rehab and wait”), options should be attempted first. And others who simply say, “let’s heal with cold steel.” That is, some in the surgical profession take a highly pragmatic attitude toward such things, believing it best just to go in, fix the problem, and everyone moves on, albeit with challenges. It’s an old-school, somewhat tongue-in-cheek saying that reflects the idea that surgical intervention is their method of healing, in contrast to medication or non-invasive treatments. It’s more common among military or trauma surgeons but can be heard in broader surgical culture. The point to take away though, is the idea that even if there’s risks, and on occasion complications, the goal is to definitively try – inasmuch as possible – to just fix the problem.

Graft Options

ACL reconstruction requires a tissue graft to replace the torn ligament. A graft is a piece of tissue used to replace the damaged ACL, acting as a scaffold for new ligament growth and eventually integrating into the knee as a functional substitute. Common options include:

• Autografts (from your own body):
  
  • Patellar tendon: Often called the “gold standard,” it offers excellent strength and bone-to-bone healing but can cause anterior knee pain.
    
  • Hamstring tendons: Less donor site pain but potentially longer healing time at insertion sites.
    
  • Quadriceps tendon: Good alternative with less donor site morbidity than patellar tendon.
    
• Allografts (from a donor):
  
  • Advantages include no donor site challenges and shorter surgery time.
  • Potential disadvantages include longer incorporation time, higher failure rates in young athletes, and a minimal risk of disease transmission, though this is extremely rare with modern screening.
    
  • Often strongly recommended for older patients as their own “spare parts” may not be appropriate. What constitutes and older patient? That in itself is debatable. Some surgeons may be thinking this is anyone in their late 30s and on, others not until 50s. Part of the issue also depends on intent; just fix? Or return to sports? Return to casual sports? Or still a professional athlete? Most of us don’t have to worry about the pro athlete issues! They’ll have a whole medical staff supporting their choices and rehab.
    
• Emerging Options (there are newer options emerging, but are still less common.)
  
  • Synthetic Grafts
    • Examples: LARS (Ligament Advanced Reinforcement System), Gore-Tex.
    • Pros: No donor site issues, immediate strength.
    • Cons: Higher failure rates historically, risk of inflammation or long-term complications.
    • Status: Rare in the U.S., more common in parts of Europe and Asia; sometimes used in revisions.
      
  • Hybrid Grafts
    • Combination of autograft + allograft, often used in revision surgeries or complex cases where extra graft volume is needed.
    • Goal: Balance the benefits of each type (e.g., strength from autograft, volume from allograft).
      
  • Contralateral Autograft
    • Using tissue from the opposite knee, typically if the injured knee lacks good graft options or after a failed previous surgery.
    • Tradeoff: Doubles rehab complexity but preserves options when the injured side has been “used up.”
      
• BEAR Technique (Perhaps requires it’s own category. BEAR, (Bridge-Enhanced ACL Repair). is a newer, biologic approach to ACL treatment that differs from traditional ACL reconstruction. Instead of replacing the torn ACL with a graft, BEAR aims to repair and stimulate healing of the patient’s own ligament.
  • Involves placing a special protein-based implant (a sponge-like scaffold) between the torn ends of the ACL.
  • The implant is to stimulate healing and acts as a bridge for the ligament to regrow.
  • Advantages: Preserves the native ACL tissue, Avoids graft harvest, Some early studies show similar stability and less muscle weakness compared to reconstruction, May result in a more “natural” knee after healing.
  • Limitations / Issues: Not yet as widely available or studied long-term as traditional reconstruction, Only appropriate for certain types of ACL tears, typically acute (within 50 days) and with a good-quality ligament stump. Still under evaluation for long-term durability, especially in high-level athletes. It seems to be becoming more common after FDA approval in 2020, espcially for good candidates, such as young, healthy athletes.

Surgical Techniques

In association with your care team, (typically primarily your surgeon), you’ll consider the options given your situation. Sometimes the choice may be relatively easy, other times many factors may come into play. In the end, you’re dealing with a lot of unknowns and probabilities. Factors for deciding will include age and activity level, if ongoing sports are desired and if so, what types. As well, recovery preference and types. Surgeons may have their own preference as well, based on their preferred technique and experience. Some may not even offer all graft types.

Bottom line: There’s no one-size-fits-all. The decision should involve a detailed discussion between you and your surgeon about your goals, anatomy, and recovery expectations.

Surgical Techniques

Modern ACL reconstruction is typically performed arthroscopically. Arthroscopically means using a minimally invasive surgical technique where a small camera (called an arthroscope) and specialized instruments are inserted into the joint through tiny incisions. This approach allows for precise work with less tissue damage, smaller scars, less pain, and faster recovery compared to open surgery. Options may involve:

• Single-bundle reconstruction: Traditional approach replacing the torn ACL with a single graft bundle.
• Double-bundle reconstruction: Attempts to replicate both functional bundles of the native ACL.
• All-inside technique: Minimizes incisions and bone drilling.
• Anatomic reconstruction: Focuses on placing the graft at the native ACL attachment sites.

Scheduling

If possible, considering scheduling your surgery for early in the week, and not before any holiday times. Why? If you do have any issues during the first week, you want to have your surgeon or at least their office available; at least during typical business hours. There’s little more nerve-wracking that having questions like,”I’m in a lot of pain, can I take another pill,” but it’s 8:00 PM on a Friday evening and you’re not going to be able to get to your own care team until Monday. (Ideally, you’ll have an emergency number for them though. But still, it’s going to be more challenging.)

Other Issues

Often, an ACL injury will be accompanied by additional knee injuries. Make sure to fully explore the various options for different additional concomitant problems.

📰 Web Articles

ACL Surgery – New York Hospital for Special Surgery
ACL Injury: Does It Require Surgery?
ACL Reconstruction Graft Options
Types of Surgical Procedures to Repair an ACL
ACL Graft Options
ACL Surgery: Overview

🎥 Videos

ACL Tears: Treatment Options for Active Adults
ACL Tears – Your Treatment Options
What are the different ACL Grafts? | Which one is best? Patella vs Hamstring
How do I choose a graft for ACL reconstruction? – Stanford Children’s Health
Anterior Cruciate Ligament (ACL) Reconstruction Surgery – Explained
Understanding ACL Reconstruction: Types and Procedures Explained
Guide to ACL Surgery: Expectations, Procedures, and Rehabilitation – Ask Mayo Clinic Health System
ACL Treatment Options and BEAR Procedure