Current Recommendations for ACL Reconstruction
For acute isolated ACL tears requiring surgery, perform early reconstruction within 3 months using either bone-patellar tendon-bone (BPTB) or hamstring autograft, with BPTB preferred when minimizing graft failure risk is the priority, and consider adding lateral extra-articular augmentation with hamstring grafts in high-risk patients. 1
Surgical Timing
Early reconstruction is strongly recommended within 3 months of injury to reduce the risk of additional cartilage and meniscal damage. 1 This represents a shift toward more aggressive early intervention, as the risk of secondary injuries begins increasing within this timeframe. 1
Graft Selection Algorithm
Primary Considerations
When choosing between autograft options for skeletally mature patients, the decision hinges on balancing failure risk against donor site morbidity:
BPTB Autograft - Favor when:
- Minimizing graft failure is the highest priority (2.80% failure rate vs 2.84% for hamstring) 2
- Patient is young and highly active 3
- Reducing infection risk is important 1, 3
- Patient can tolerate anterior/kneeling pain 1
Hamstring Autograft - Favor when:
- Avoiding anterior knee pain is critical 1
- Patient has concerns about kneeling pain 1
- Graft diameter is ≥8mm (caution in shorter patients where adequate diameter may not be achievable) 4
Quadriceps Tendon - Consider when:
- Seeking comparable graft survival to BPTB and hamstring 5
- Minimizing donor site morbidity is a priority (lower than both BPTB and hamstring) 5
- Patient wants to avoid specific complications of other grafts 5
Critical Caveat on Graft Failure Rates
While BPTB shows statistically lower failure rates than hamstring (2.80% vs 2.84%), the absolute difference is minimal—you would need to treat 235 patients with BPTB over hamstring to prevent one graft rupture. 2 Both grafts demonstrate similar stability outcomes on instrumented testing, pivot shift, and Lachman examination. 2
Surgical Technique
Single-bundle versus double-bundle reconstruction: Either technique is acceptable as outcomes are equivalent between the two approaches. 1 This strong recommendation allows surgeon preference and experience to guide technique selection.
Emerging Augmentation Strategies
A significant new recommendation for 2023: Consider anterior lateral ligament (ALL) reconstruction or lateral extra-articular tenodesis (LET) when performing hamstring autograft reconstruction in select patients to reduce graft failure and improve short-term function. 1 This represents an important evolution in addressing the slightly higher failure rate of hamstring grafts, though long-term outcomes remain unclear. 1
Concomitant Injuries
For combined ACL/MCL tears: Reconstruct the ACL but treat the MCL non-surgically in most cases, as this approach yields good outcomes. 1 Surgical MCL treatment may be considered in select cases, but this is not the default approach. 1
Return to Sport Criteria
Functional evaluation such as hop testing should be considered as one factor in determining return to sport clearance, aiming for criterion-based rather than purely time-based progression. 1, 6 Return to running should not occur before 12 weeks minimum, with most patients requiring 9-12 months of rehabilitation before full return to sport. 6
What NOT to Do
Do not perform ACL repair instead of reconstruction - reconstruction has lower revision surgery rates. 1
Do not routinely use functional knee braces after isolated primary ACL reconstruction - they provide no clinical benefit. 1
Do not use prophylactic knee bracing to prevent ACL injury - this is not effective. 1
Avoid allograft in younger patients - failure rates increase significantly in this population; reserve allografts for patients over 35 years old or revision cases. 7
Prevention
Training programs designed to prevent ACL injury should be implemented for athletes in high-risk sports, as these can reduce primary ACL injury risk. 1