ACL Reconstruction

Why this approach — at MOS

ACL reconstruction decisions are not one-size-fits-all, and we approach each patient individually. For athletes, the conversation begins with graft selection — which graft offers the best combination of mechanical properties, failure risk, and donor-site morbidity for this specific person's sport, position, age, anatomy, and future surgical history. For a 17-year-old soccer player with a grade 2 pivot-shift and plans to play at the college level, we have a very different conversation than with a 45-year-old recreational cyclist with an incidentally noted partial tear and no functional instability.

Our surgeons have served as team physicians at the NFL, MLB, MLS, and NCAA levels, providing on-field and sideline care for professional and collegiate athletes with ACL injuries across multiple sports. This experience informs our clinical decision-making — we have seen what happens when graft selection is mismatched to activity demands, when reconstruction is timed poorly relative to acute swelling, and when return-to-sport criteria are not objectively enforced.

We perform ACL reconstruction using arthroscopic technique with anatomic tunnel placement confirmed intraoperatively. For patients who meet LET criteria, we add the modified Lemaire procedure during the same anesthetic. We use locoregional nerve blocks to minimize postoperative opioid requirements, and our physical therapy team — available at all three MOS offices in Bethesda, Germantown, and Rockville — begins the rehabilitation protocol within the first week of surgery.

For low-demand patients, our conservative-first philosophy means we do not reflexively recommend surgery. A 55-year-old with a sedentary lifestyle and an ACL tear who has no giving-way episodes is not automatically an ACL reconstruction candidate.

Who is a candidate?

Indications

• Complete ACL tear confirmed on MRI in a patient with functional instability (giving way during daily activities or sport)
• Partial ACL tear with persistent functional instability after supervised physical therapy
• ACL tear with associated injuries (meniscus tear requiring repair, multiligament injury) where knee stability is needed to protect the repair
• Young, active patients (competitive or recreational athletes) with any degree of ACL tear and plans to return to pivoting or cutting sports
• Patients whose occupation requires physical demands that exceed what a braced, conservatively managed knee can provide

Contraindications / Patients Who May Not Need Surgery

• Older, sedentary patients with a complete ACL tear who do not perform pivoting activities and have no functional instability — non-surgical management with physical therapy and activity modification is often appropriate
• Patients with severe tricompartmental knee arthritis where joint replacement is the more appropriate surgery
• Patients with active infection, poor skin condition, or other surgical risk factors that outweigh the benefit
• Skeletally immature patients with significant growth remaining — physeal-sparing techniques are required; standard tunnels are contraindicated

Conservative Treatment First

Not every ACL tear requires surgery. For lower-demand patients — those who do not participate in pivoting sports, whose work is sedentary, and who do not experience functional instability during daily activities — a structured physical therapy program focused on quadriceps and hamstring strengthening can provide adequate knee function without reconstruction. This is sometimes called ACL rehabilitation or "functional bracing plus PT."

At Maryland Orthopedic Specialists, the decision to proceed with reconstruction begins with an honest assessment of functional demand, age, instability symptoms, and associated injuries. Patients who present with their first ACL tear are offered a trial of physical therapy before committing to surgery if their situation makes non-surgical management a reasonable option. However, for competitive athletes, patients with concurrent meniscus tears requiring repair, or patients with documented giving-way episodes, reconstruction is typically recommended promptly — delay can allow secondary meniscal damage that complicates long-term knee health.

The procedure

What Is ACL Reconstruction?

ACL reconstruction is surgery to rebuild the anterior cruciate ligament — the central stabilizing ligament of the knee — using a tendon graft. It is performed when the ACL is fully torn and the knee remains unstable despite physical therapy, most often in active patients who want to return to pivoting sports or physical work.

The anterior cruciate ligament runs diagonally through the center of the knee, connecting the back of the femur (thigh bone) to the front of the tibia (shin bone). Its primary job is to control rotational stability and prevent the tibia from sliding forward relative to the femur during cutting, pivoting, and landing movements. When it tears — which it typically does without contact, during a deceleration or direction change — the knee loses this check and gives way unpredictably.

Unlike most tendons, a torn ACL does not reliably heal on its own. The ligament's blood supply and the mechanical environment inside the joint make self-repair unlikely in most cases. This is why reconstruction — rather than simple repair — is the standard surgical treatment. The procedure removes the torn ligament remnants and replaces them with a new graft, which is secured inside bone tunnels drilled through the femur and tibia. Over the following 12 to 18 months, a process called ligamentization converts the graft into functional ligament tissue.

At Maryland Orthopedic Specialists, ACL reconstruction is performed by fellowship-trained surgeons with extensive experience in competitive athletes as well as recreational and occupational patients. The most consequential decision in ACL reconstruction is graft selection — and it is individualized to each patient's age, activity demands, anatomy, and prior surgery history.

What Happens During ACL Reconstruction?

ACL reconstruction is performed as an outpatient procedure, meaning patients go home the same day. The surgery takes place under general or spinal anesthesia, with the patient positioned supine on the operating table with the knee bent to approximately 90 degrees.

Step 1 — Arthroscopic examination. The surgeon inserts a small camera (arthroscope) through one or two small incisions around the knee to inspect the entire joint: the ACL, PCL, menisci, articular cartilage, and synovium. Any associated meniscus tears or cartilage problems are addressed before graft placement.

Step 2 — Graft harvest. For autograft procedures (using the patient's own tissue), the tendon graft is harvested through a separate small incision. The harvest site and technique depend on which graft type is chosen — patellar tendon, quadriceps tendon, or hamstring tendons. For allograft procedures, no harvest incision is needed.

Step 3 — Tunnel drilling. The torn ACL remnants are removed from the joint using a shaver and electrocautery. Bone tunnels are precisely drilled through the tibia and femur at the anatomic footprint of the original ACL. Tunnel placement is the most technically demanding part of the procedure — millimeter-level accuracy determines the function of the reconstructed ligament.

Step 4 — Graft passage and fixation. The prepared graft is threaded through the tibial tunnel, across the joint, and into the femoral tunnel. The graft is tensioned and fixed in place using interference screws, cortical buttons, or a combination of fixation devices, depending on graft type and surgeon preference.

Step 5 — Lateral extra-articular tenodesis (LET), if indicated. For high-risk patients — typically younger patients, those with significant rotational laxity, or those with a pivot-shift grade 2 or higher — an LET procedure may be added during the same anesthetic. This involves creating a check-rein using a strip of the iliotibial band to control anterolateral rotatory laxity. See the section below for details.

Step 6 — Closure and recovery room. Incisions are closed with absorbable sutures, the knee is wrapped in a compressive dressing, and the patient moves to the recovery area. Most patients are discharged within 2–3 hours with crutches, a knee brace, and ice therapy instructions.

Graft Selection: The Most Consequential Decision

The tendon graft chosen to replace the torn ACL is arguably the most important variable in ACL reconstruction outcomes. Graft selection should be individualized — no single graft is optimal for every patient. The four main options are:

| Graft Type | Source | Key Advantage | Primary Limitation | |---|---|---|---| | Patellar Tendon (BPTB) | Middle third of patellar tendon + bone plugs | Bone-to-bone healing; gold standard for competitive athletes | Anterior knee pain, kneeling discomfort | | Quadriceps Tendon | Central third of quadriceps tendon | Largest cross-sectional area; less anterior knee pain than BPTB | Quadriceps weakness in early recovery | | Hamstring (ST/G) | Semitendinosus ± gracilis, quadrupled | Lower donor-site morbidity; smaller incision | Higher failure in young high-demand athletes vs. BPTB | | Allograft | Cadaveric tendon (patellar, Achilles, anterior tibialis) | No donor site; shorter surgery; appropriate for older/lower-demand patients | Significantly higher re-rupture rates in young athletes |

Each graft type has a dedicated page with full clinical detail:

• ACL Reconstruction — Patellar Tendon Graft — Bone-patellar tendon-bone: the historical gold standard for competitive athletes
• ACL Reconstruction — Quadriceps Tendon Graft — An increasingly favored option, especially for younger patients and revision cases
• ACL Reconstruction — Hamstring Tendon Graft — Gracilis/semitendinosus: lower donor-site morbidity with appropriate patient selection
• ACL Reconstruction — Allograft — Cadaveric tissue: appropriate for older and lower-demand patients; not recommended for young athletes

Lateral Extra-Articular Tenodesis (LET) as an Augmentation

LET is an additional procedure performed at the same time as intra-articular ACL reconstruction to control anterolateral rotatory instability — the "pivot-shift" component that some patients experience even after a successful standard reconstruction.

When LET is used at MOS: Patients who meet high-risk criteria: age under 25, grade 2 or higher pivot-shift on examination, desire to return to high-level pivoting sports, and/or generalized ligamentous laxity. It is most commonly added to hamstring graft reconstructions, where residual rotatory laxity is more common than with stiffer autograft options.

The STABILITY trial evidence: The STABILITY Study (Getgood et al., Am J Sports Med, 2020) is the definitive level 1 randomized controlled trial on LET. In 618 patients aged 14–25, adding LET to hamstring ACL reconstruction reduced graft rupture by 67% (11% rupture rate in ACLR-only group vs. 4% in ACLR+LET group, p<0.001) and reduced overall clinical failure by 38%. The number needed to treat to prevent one graft rupture was 14.3 patients over two years. Importantly, LET did not significantly increase adverse event rates.

Technique: MOS surgeons use a modified Lemaire technique, in which a strip of the iliotibial band is routed beneath the fibular collateral ligament and fixed to the lateral femoral condyle. The procedure adds approximately 20–30 minutes to the operative time and does not require a separate incision beyond the lateral exposure.

Recovery timeline

Frequently Asked Questions

Meet the surgeons

Christopher S. Raffo, MD

Orthopedic Surgery · Sports Medicine

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John J. Christoforetti, MD

Orthopedic Surgery · Sports Medicine · Hip Preservation Surgery

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James S. Gardiner, MD

Orthopedic Surgery · Sports Medicine

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