What is the recommended treatment for a patient with a torn anterior cruciate ligament (ACL)?

Treatment of Torn Anterior Cruciate Ligament

For patients with a torn ACL requiring surgery, perform early arthroscopic ACL reconstruction within 3 months using bone-patellar tendon-bone (BPTB) autograft as the first-line choice, particularly in young, active patients where minimizing graft failure risk is paramount. 1, 2, 3

Surgical vs. Non-Surgical Decision

• ACL reconstruction is strongly recommended for younger and more active patients to lower the risk of future meniscus pathology, additional cartilage damage, and to improve long-term pain and function 1
• Reconstruction should be chosen over repair due to lower risk of revision surgery 1
• Non-surgical management may be considered in older, less active patients, though this is not the primary recommendation for most cases 1

Critical Timing Consideration

• Perform reconstruction within 3 months of acute injury to prevent additional cartilage and meniscal damage—this is a strong recommendation that should be followed unless compelling contraindications exist 1, 2, 3
• Delaying beyond 3 months significantly increases the risk of secondary injuries that worsen long-term outcomes 2, 3

Graft Selection Algorithm

First-Line: BPTB Autograft

Choose BPTB when:

• Patient is young and highly active with high-demand athletic goals 2, 3
• Minimizing graft failure risk is the highest priority 1, 2, 3
• Reducing infection risk is important 1, 2
• Maximum knee stability is required for high-demand activities 2

Trade-offs to discuss:

• Higher risk of anterior knee pain and kneeling pain compared to hamstring 1, 2, 4
• Potential for loss of knee extension range of motion 4
• Better return-to-sport rates (81.0% vs 70.6% for hamstring) 5

Second-Line: Hamstring Autograft

Choose hamstring when:

• Avoiding anterior knee pain is the patient's primary concern 1, 2, 3
• Patient has occupational requirements involving frequent kneeling 2
• Lower donor site morbidity is desired 2

Trade-offs to discuss:

• Higher graft failure risk compared to BPTB 1, 2
• Consider adding lateral extra-articular augmentation to reduce re-rupture risk 2, 3
• Potential for loss of knee flexion strength 4

Alternative: Quadriceps Tendon Autograft

• May be considered when neither BPTB nor hamstring is suitable 6, 7
• Offers larger, stronger graft with less donor site morbidity than BPTB 6
• Less established in guidelines but emerging as viable option 7

Surgical Technique

• Both single-bundle and double-bundle reconstruction techniques produce equivalent outcomes—surgeon preference and experience should guide technique selection 1, 2, 3

Concomitant MCL Injury

• For combined ACL/MCL tears, reconstruct the ACL surgically but treat the MCL non-surgically in most cases, as this yields good outcomes 1, 3
• Surgical MCL treatment may be considered only in select cases 1

What NOT to Do

• Do not use functional knee braces routinely after isolated primary ACL reconstruction—they provide no clinical benefit 1, 2
• Do not delay reconstruction beyond 3 months in young, active patients 2, 3
• Do not use artificial grafts—autograft options are strongly preferred 2

Return to Sport Criteria

• Use criterion-based progression with functional evaluation (such as hop testing) rather than purely time-based clearance 2, 3
• Implement ACL injury prevention training programs for athletes in high-risk sports to reduce primary injury risk 1, 3