ACL Injuries Surgical Treatment

Patients who return to cutting and pivoting sports on an ACL-deficient knee face high rates of recurrent instability, and each episode of giving way risks new damage to the meniscus and cartilage. For these patients, and for anyone with a repairable meniscus tear or multi-ligament injury, Dr. Rynecki Baker will discuss ACL reconstruction as a way to protect the knee for the long term rather than waiting for further injury. Surgery is also recommended when instability persists despite rehabilitation.

Before surgery, patients complete a period of “prehabilitation” to restore full extension, calm the swelling, and rebuild quadriceps strength, which meaningfully improves outcomes after reconstruction. Surgery is performed sooner when a displaced meniscus tear is locking the knee or when multiple ligaments are injured, and early repair is beneficial.

Because a torn ACL cannot reliably be sewn back together, the ligament is most often replaced with a graft. Dr. Rynecki Baker performs ACL reconstruction arthroscopically, working through small incisions with a camera that provides a magnified view inside the joint. The procedure is performed on an outpatient basis, and most patients go home the same day.

Tunnels are created in the femur and tibia at the ligament’s native attachment sites. Accurate tunnel placement is one of the most important technical factors in a successful reconstruction. The graft is passed through the tunnels and secured at both ends, restoring front-to-back and rotational stability. Over the first year, the graft gradually becomes living ligament tissue.

Graft choice is individualized to each patient’s anatomy, sport, and goals:

• Quadriceps tendon autograft: Uses the patient’s own quadriceps tendon and has become a workhorse graft because of its strength and reliably large size.
• Bone-patellar tendon-bone autograft: Uses the central third of the patellar tendon with a block of bone at each end, offering bone-to-bone healing that many high-demand pivoting athletes prefer.
• Hamstring autograft: Uses the patient’s own hamstring tendons and avoids disturbing the extensor mechanism.
• Allograft: Donor tissue avoids harvesting the patient’s own tendon and is generally reserved for older or lower-demand patients and for certain revision and multi-ligament cases, as allografts carry higher retear rates in young athletes.

In select patients, preserving the native ligament may be an option. Primary ACL repair can be considered for tears that pull off the femoral attachment with good-quality tissue remaining. Bio-enhanced repair techniques, which use a scaffold to help the torn ligament heal, are also being studied.

These approaches have shown promise in specific patient groups but have demonstrated higher reoperation rates in young, highly active athletes compared with reconstruction. Candidacy depends on tear pattern, tissue quality, age, and activity goals.

Many ACL reconstructions include treatment of associated injuries:

Meniscus repair

Dr. Rynecki Baker prioritizes meniscus repair whenever the tear pattern and tissue quality allow, because preserving meniscal tissue protects the cartilage and lowers the long-term risk of arthritis. She specifically evaluates for a ramp lesion, a tear at the back inner corner of the medial meniscus that is easily missed, and repairs it when present. If the meniscus cannot be repaired, the torn portion will be removed which is called a meniscectomy.

Lateral extra-articular tenodesis (LET) or anterolateral ligament reconstruction

Adds rotational control on the outside of the knee in young pivoting athletes, patients with high-grade rotational laxity, generalized ligamentous laxity, or excessive knee hyperextension, and those undergoing revision surgery. The STABILITY trial, a large multicenter randomized study of more than 600 high-risk patients aged 25 and under, found that adding an LET to a hamstring autograft reconstruction reduced the risk of graft rupture from roughly 11% to 4% and cut overall clinical failure from 40% to 25% at two years.

Collateral and multi-ligament reconstruction

When the MCL, PCL, or posterolateral corner are injured and will not heal adequately on their own, those structures are repaired or reconstructed as part of the surgical plan to protect the ACL graft.

Children and adolescents who are still growing require special consideration, as standard tunnels can cross the growth plates. For these patients, Dr. Rynecki Baker uses growth plate-sparing or growth plate-respecting techniques, selected according to the patient’s remaining growth, to restore stability while protecting normal development of the leg.

When a prior reconstruction has failed, careful evaluation identifies why. Common causes include tunnel malposition, a missed or untreated associated injury, a new traumatic event, and bony factors such as excessive tibial slope or malalignment. A CT scan assesses tunnel position and size. Revision surgery may be performed in one stage or, when tunnels are enlarged, in two stages with bone grafting first. An LET is frequently added, and an osteotomy to reduce tibial slope or correct alignment may be recommended in select cases.

Recovery from ACL surgery requires commitment to a structured rehabilitation program. Early goals are restoring full knee extension, controlling swelling, and reactivating the quadriceps, all of which strongly predict the eventual outcome. Most patients use crutches for a short period, with weight-bearing and bracing adjusted if a meniscus repair or ligament reconstruction was performed. Physical therapy progresses from range of motion and strengthening to balance, agility, and eventually sport-specific training.

Return to cutting and pivoting sports typically occurs at nine to twelve months and is guided by strength testing, hop testing, movement quality, and psychological readiness rather than the calendar alone. The goal is a return to sport and daily activity on a knee you can trust.