Overview
The anterior cruciate ligament runs diagonally inside the knee joint, connecting the femur to the tibia. It is the primary restraint against the tibia sliding forward and against rotational pivoting — exactly the forces generated during cutting and landing in sport. A torn ACL leaves the knee unstable for pivoting activity and often accompanies meniscal and cartilage injuries that compound over time.
How the Procedure Works
The first decision is graft selection. Patellar tendon (bone-tendon-bone) offers bone-to-bone healing at both ends and is our preference for high-demand athletes; hamstring tendons are a reliable alternative, particularly when avoiding patellar donor-site morbidity matters; quadriceps tendon has become an increasingly common choice for its graft bulk with modest donor-site impact. After the torn ACL is cleared arthroscopically, we drill femoral and tibial tunnels at the anatomic footprints — slightly off-center placements translate directly into rotational instability and re-tear risk, so tunnel position is the most technique-sensitive step. The graft is tensioned and secured at both ends under anatomic load; we stress-test the reconstruction before closing to confirm stability at the full arc of motion. The graft is not a ligament yet — it remodels gradually under progressive loading, which is why rehabilitation pacing matters as much as the surgery.
When to Consider ACL Reconstruction
ACL reconstruction is generally offered when symptoms, imaging, and a trial of non-operative care together point to surgery as the next step. The typical picture includes:
Active patients wishing to return to sport
Athletes who want to return to pivoting or cutting sports — soccer, basketball, skiing, football — where a stable ACL is non-negotiable.
Young patients with a long active life ahead
Reconstruction protects the meniscus and cartilage from the repeated giving-way episodes an ACL-deficient knee produces.
Associated injuries that need addressing
Meniscal tears, cartilage damage, or multi-ligament injury that should be surgically managed at the same sitting.
Conditions This Treats
Physicians Who Perform ACL Reconstruction
Providers Who Surgically Assist with ACL Reconstruction
Risks & Why We Still Recommend It
Every operation carries risk. The reason we offer this procedure is that the condition, left untreated, causes repeated giving-way that damages the meniscus and cartilage a little more each time and closes off pivoting sports for good. That is the trade we are managing — not eliminating risk, but choosing the smaller of two unfavorable trajectories.
The risks we discuss with patients before acl reconstruction include:
- bleeding and infection
- anesthesia risk
- graft-site pain (patellar or hamstring) that usually settles
- stiffness or loss of terminal extension
- graft re-tear, especially with early return to cutting sport
- blood clot (DVT/PE)
- rarely, injury to nearby nerves or vessels
The indication to proceed is a functionally unstable knee in a patient who wants to return to pivoting activity, confirmed on exam and MRI. Patients who don't need this operation don't get it.
Further Reading
External patient-education references and related OSI pages for additional background: