Anterior cruciate ligament injury
The goal of anterior cruciate ligament (ACL) reconstruction is to restore knee stability and create the best possible conditions for a safe return to physical activity and sport. Surgery is planned individually based on the patient’s goals, knee stability, sport, anatomy and any concomitant injuries.
Surgical treatment is particularly appropriate when the knee has functional instability or when the patient aims to return to a sport involving substantial pivoting, change-of-direction and rotational loading.
The decision to proceed with surgery is also influenced by meniscus injuries, other ligament injuries, the patient’s age and activity level, and the individual risk of reinjury.
• recurrent giving-way episodes or a sense of instability
• planned return to a pivoting or change-of-direction sport
• repairable meniscus injury
• significant rotational laxity on clinical examination
• concomitant ligament injuries
• high individual risk of reinjury
The decision to operate is not based solely on an ACL tear seen on MRI, but on the overall function of the knee and the patient’s individual goals.
ACL reconstruction is not the same procedure for every patient.
Surgical planning includes an assessment of anteroposterior and rotational knee stability, the menisci, other ligaments, the patient’s anatomy, and any previous injuries or operations.
Particularly in patients at high risk of reinjury, several risk factors may accumulate.
• high-grade pivot shift
• young age and high activity level
• participation in a pivoting or change-of-direction sport
• general joint hypermobility
• increased posterior tibial slope
• meniscal root or posterior horn injury
• concomitant ligament injuries
For ACL reconstruction, I use the three most common autograft options according to the individual patient: a hamstring tendon autograft, a bone–patellar tendon–bone (BTB) autograft, or a quadriceps tendon autograft.
There is no single best graft for every patient.
Graft selection is influenced by factors including:
• patient's age
• sport and target level
• physical demands
• patient anatomy
• previous surgeries
• other concomitant procedures
• individual risk of reinjury
The graft is selected according to the individual patient and the demands of the sport, rather than using a one-size-fits-all approach.
In an ACL injury, the menisci are always carefully evaluated.
A repairable meniscus tear is preserved and repaired whenever biologically and technically possible.
This also applies to injuries such as meniscal root and ramp lesions, which can affect knee stability and increase the load on the reconstructed ACL.
Preserving the meniscus is important for both knee function and long-term joint health.
The goal of ACL reconstruction is not simply to reconstruct the ACL, but to restore the stability of the entire knee and protect the menisci
An anterior cruciate ligament (ACL) injury may also be associated with damage to other structures that affect the stability of the knee.
For example, an injury to the medial collateral ligament, an injury to the anterolateral complex, or another multi-ligament injury can alter both the surgical plan and rehabilitation.
Each concomitant injury is assessed individually as part of the overall stability of the knee.
The risk of reinjury is rarely determined by a single factor. Multiple risk factors can accumulate.
In selected high-risk patients, ACL reconstruction can be combined with an additional procedure aimed at reducing rotational laxity of the knee and the risk of reinjury.
One such procedure is lateral extra-articular tenodesis, or LET.
LET can be considered, for example, when the patient has multiple risk factors for reinjury, severe rotational instability, or the goal is to return to a high-risk pivoting sport.
In high-risk ACL injuries, the surgical strategy can be tailored to reduce the risk of reinjury.
ACL reconstruction restores the mechanical stability of the knee, but a successful return to exercise and sports also requires long-term rehabilitation.
Factors affecting the return:
• biological healing
• front and back thigh muscle strength
• business management
• functional performance
• psychological readiness
• sport-specific load tolerance
The biological maturation of the anterior cruciate ligament graft continues for months, even if the knee already feels good earlier.
The success of a surgery is not determined by the surgical procedure alone. The final outcome is a combination of the surgery, rehabilitation, and a safe Return to Sport process.
Returning to sports is not based solely on the time since surgery.
Before returning, muscle strength, functional performance, movement quality, psychological readiness, and sport-specific load tolerance are objectively assessed.
Surgery →
rehabilitation →
progressive loading by species →
Return to Sport