Navigating ACL treatment and recovery

When an ACL tear occurs, natural healing is rare due to poor blood supply. Here, we delve into surgical reconstruction, graft selection, and the path to recovery.

Understanding your treatment options

Now that we’ve talked about why ACL injuries happen and why certain athletes are at higher risk, let’s shift into how these injuries are treated—specifically, surgical reconstruction and graft selection. For athletes who want to return to sport, especially at a high level, ACL reconstruction is often the most effective option to restore knee stability and function.

Why surgery?

When the ACL is torn, it rarely heals on its own due to poor blood supply, making surgical reconstruction a key solution for athletes. ACL tears are diagnosed with scans such as X-rays and MRIs.

Graft choices explained

There are three primary graft choices: the bone-patellar tendon-bone (BPTB), hamstring tendon, and quadriceps tendon grafts. Additionally, there are allograft options which use a cadaver ligament to replace the damaged one.

Autograft vs Allograft

In ACL reconstruction, an autograft uses tissue taken from the patient’s own body, while an allograft uses donor tissue from another person

Your path to recovery and sport

ACL reconstruction is a highly effective option for athletes to regain stability and function.

Bone-Patellar Tendon-Bone Autograft

Let’s start with the bone-patellar tendon-bone, or BPTB, autograft. This has historically been considered the “gold standard” for high-level athletes.

In this procedure, the surgeon takes the central third of the patellar tendon, along with small bone plugs from the kneecap and the tibia. These bone plugs are then secured into tunnels that are drilled into the femur and tibia. One of the biggest advantages of this graft is something called bone-to-bone healing. Because the graft includes bone on both ends, it integrates more quickly and reliably into the surrounding bone tissue. This leads to strong initial fixation and allows for a stable reconstruction early in the recovery process. As a result, some athletes may be able to progress more aggressively through rehabilitation.

Another reason this graft is so popular is that the patellar tendon closely resembles the native ACL in terms of its strength, stiffness, and collagen structure. This allows it to handle the high forces involved in sports like soccer, including cutting, jumping, and rapid deceleration.

However, this graft does come with some downsides. Athletes may experience anterior knee pain, pain when kneeling, or even symptoms similar to jumper’s knee after surgery.

Hamstring Graft Autograft

This procedure typically involves harvesting the semitendinosus tendon, and sometimes the gracilis tendon, and then folding them to create a strong, multi-strand graft. One major advantage of this approach is that it causes less disruption to the front of the knee. Because of that, athletes often report less anterior knee pain compared to the patellar tendon graft. It also provides a good amount of tendon tissue, which can be layered to increase the strength of the graft.

However, there are some important considerations.
The hamstrings play a key role in stabilizing the knee by preventing the tibia from moving forward. So when these tendons are harvested, it can temporarily weaken the hamstring muscle group. This is especially important in female athletes, who may already have less hamstring activation compared to quadriceps dominance. If hamstring strength is not fully restored during rehabilitation, the reconstructed ACL may be placed under more stress during movement.

Additionally, because this graft involves soft tissue attaching to bone rather than bone-to-bone healing, the integration process can take longer. This can sometimes result in slightly increased knee laxity after surgery and, in some cases, higher failure rates.
There can also be challenges early in rehab, such as difficulty achieving full knee extension, which is essential for normal walking mechanics and overall stability

Quadricep Tendon Autograft

This is a newer option that has become increasingly popular, especially among athletes who want a strong graft but fewer complications associated with the patellar tendon. The quadriceps tendon is thicker and larger than both the patellar and hamstring tendons, which allows surgeons to harvest a graft with a greater diameter. This graft can also be taken with or without a bone plug, giving surgeons more flexibility in how they perform the procedure.

One of the biggest advantages is its strength. The dense collagen structure provides high tensile strength, and the larger surface area helps with integration into surrounding tissues. Another benefit is that removing part of the quadriceps tendon typically has less impact on overall muscle strength compared to harvesting the hamstrings. Patients also tend to experience less anterior knee pain than with the patellar tendon graft, while still maintaining strong mechanical stability.

Because of the combination of strength, reduced pain, and good outcomes, this graft is becoming more popular among both surgeons and high-performance athletes.

ACL Reconstruction Procedure

ACL reconstruction is typically performed arthroscopically, using small incisions and a camera to guide the surgery. If an autograft is used, there will also be a small incision at the site where the graft is harvested. During the procedure, the surgeon first removes any damaged remnants of the torn ACL. Then, tunnels are carefully drilled into the femur and tibia in positions that replicate the natural origin and insertion of the ACL. The graft is then passed through these tunnels and secured using fixation devices.

Graft choice Importance

Each of these options has its own advantages and disadvantages, which is why graft selection is highly individualized. The best choice depends on factors such as the athlete’s sport, anatomical considerations, injury history, and long-term performance goals. For example, athletes in high-demand, cutting or pivoting sports may prioritize graft strength and durability, while others may focus on minimizing recovery time or avoiding additional surgical sites. Surgeons must also consider the patient’s overall health, risk of re-injury, and personal preferences. Because no single graft is ideal for every situation, careful evaluation of these factors helps ensure the most appropriate and effective outcome for each individual.