ACL Reconstruction

Rebuilding Stability, Restoring Confidence

The anterior cruciate ligament (ACL) is the knee's primary rotational stabiliser - it's what stops the shin bone sliding forward and twisting under the thigh bone during pivoting, cutting and landing movements. An ACL tear is one of the most common serious sports knee injuries, typically caused by a sudden change of direction, an awkward landing, or a direct blow to the knee, often accompanied by a distinctive "pop" and immediate swelling.

Dr Adam Farrier is a consultant knee surgeon offering ACL reconstruction for patients in Carlisle and across Cumbria, including West Cumberland (Whitehaven), and in Newcastle upon Tyne and the North East.

Is ACL Reconstruction Right for You?

Not every ACL tear requires surgery, but reconstruction is usually recommended for patients who wish to return to pivoting sports (football, netball, skiing, rugby), for those with ongoing instability or "giving way" episodes, or where the knee remains unstable despite a course of rehabilitation. Age, activity level, and any associated injuries to the meniscus or cartilage are all taken into account when deciding whether surgery is the right path for you.

The Procedure

ACL reconstruction is performed arthroscopically (keyhole surgery), replacing the torn ligament with a graft - most commonly taken from your own hamstring or patellar tendon. The graft is carefully positioned and fixed in the same location as your original ACL, restoring the knee's rotational stability. Where a meniscal tear or cartilage injury has occurred alongside the ACL tear - common in higher-energy injuries - these can often be addressed in the same operation.

Graft Options

The new ligament is built from a tendon graft. Most commonly this is taken from your own leg (an autograft). Occasionally donor tissue (an allograft) is used. Each graft works well in the right patient.

High-quality randomised trials show that the three main autografts (hamstring, patellar tendon and quadriceps tendon) give similar results for stability, re-rupture and patient-reported function. The differences are mostly in the harvest site, which affects kneeling, early strength and scar position. That means the choice depends on you: your age, your sport, your job and your knee.

A few points worth knowing:

• Graft size matters for hamstring grafts: Hamstring grafts thinner than about 8 mm carry a higher risk of re-rupture. If your tendons are small, the graft can be tripled or quadrupled, or a different graft used.

• The quadriceps tendon is increasingly popular: Recent trial data show it matches the other autografts for stability and function, with noticeably less front-of-knee pain than the patellar tendon.

• Donor tissue is rarely used for a first ACL reconstruction in young, active patients: Re-rupture rates are higher. It has a valuable role in revision and multi-ligament surgery.

Additional Procedures to Protect the Graft

In some patients the ACL graft alone may not fully control the knee's rotational instability. This is particularly true for younger athletes and people with very loose knees. Extra procedures can be added to share the load and reduce the risk of re-rupture.

Lateral Extra-articular Tenodesis (LET)

A narrow strip of the iliotibial band (the tough band on the outside of the thigh) is re-routed and fixed to the outer thigh bone. This reinforces rotational control on the outside of the knee. It adds a small incision and around 20–30 minutes to the operation.

Evidence: The international STABILITY randomised trial studied 618 patients aged 25 or under who had high-risk features. Adding an LET to a hamstring ACL reconstruction reduced graft rupture from 11% to 4% at two years. Patients who had an LET had slightly more pain in the first three to six months. By one year, function and activity levels were the same.

Anterolateral Ligament (ALL) Reconstruction

This procedure has a similar purpose to an LET. A thin graft (often an extension of the hamstring graft) recreates the anterolateral ligament on the outside of the knee.

Evidence: A large prospective study of 502 young pivoting athletes (SANTI group) found graft rupture rates of about 4% with hamstring + ALL reconstruction. This compared with about 11% for hamstring alone and 17% for patellar tendon alone. This was a comparative cohort rather than a randomised trial, but the findings are consistent with the STABILITY results.

Who might benefit from LET or ALL reconstruction? It is typically considered if you:

• are 25 or under and returning to pivoting sport

• have a high-grade pivot shift (marked rotational looseness)

• have generalised joint hypermobility

• are having revision ACL surgery.

Internal Brace (Suture Tape Augmentation)

A strong, flat suture tape is passed alongside the graft and fixed at both ends. It acts as a "seatbelt" that protects the graft while it heals and matures.

Evidence: The evidence is promising but less mature. A 2026 meta-analysis of 11 studies (1,179 patients) found lower failure rates when hamstring grafts were augmented with suture tape (3.1% vs 8.5%), with no increase in complications. However, most studies are not randomised, and an earlier 2024 review concluded there was insufficient evidence to recommend it routinely. It may be considered in selected cases, for example with a smaller hamstring graft. Suture tape augmentation is also used with primary ACL repair for certain tear patterns.

Choosing the Right Graft for You

No single graft suits everyone. The table below summarises how age, activity and occupation typically influence the choice.

The Benefits of Reconstruction

• Restored Stability: A reconstructed ACL restores the knee's rotational control, reducing episodes of the knee giving way during pivoting or cutting movements.

• Combined Injury Management: Where meniscal or cartilage damage is present alongside the ACL tear, this can usually be treated at the same time, avoiding a second procedure.

• Protecting the Knee Long-Term: An unstable knee is more prone to further meniscal and cartilage damage over time; restoring stability helps protect these structures.

• Return to Sport: With a structured rehabilitation programme, most patients progress through a staged return to running, then sport-specific training, then competitive sport.

Important Considerations & Risks

• Graft Rupture: Like any ligament, a reconstructed ACL can be injured again, particularly with a premature return to high-risk activity before the graft has fully matured.

• Recovery Timeline: Rehabilitation is a significant commitment, typically taking 9-12 months before a safe return to pivoting sport, and requires close engagement with physiotherapy throughout.

• Graft-Site Symptoms: Depending on the graft source, some patients notice mild ongoing symptoms at the site the graft was taken from, such as hamstring tightness or kneeling discomfort.

• Additional Procedures: If an LET or ALL reconstruction is added (see above), you will have a small extra incision on the outside of the knee and may have slightly more discomfort in the first few months, which settles.

Frequently Asked Questions

How soon after injury should I have surgery?

There's no need to rush into surgery immediately. In most cases it's advisable to first settle the swelling and regain range of motion and muscle control through "pre-habilitation" before proceeding, which helps achieve a better surgical outcome.

Which graft is best?

There is no single "best" graft. Hamstring, patellar tendon and quadriceps tendon grafts give similar overall results in clinical trials, but each has strengths that suit different people. For example, a kneeling tradesperson may be better served by a hamstring or quadriceps graft, while a young footballer may benefit from a patellar or quadriceps graft or an added lateral procedure. See the Graft Options and Choosing the Right Graft for You sections above. We will decide together in clinic.

When can I return to sport?

Most patients can expect a return to pivoting sport at around 9-12 months, guided by a structured rehabilitation programme and objective strength and functional testing rather than by time alone.

Will I need an extra procedure such as an LET?

Not everyone does. It is most often recommended for younger patients returning to pivoting sports, those with very loose knees, and revision surgery. Strong trial evidence shows it reduces the risk of re-rupture in these groups. We will discuss whether it is right for you.

Dr Farrier's Note

"An ACL reconstruction is as much about the rehabilitation as it is about the surgery itself. I work closely with physiotherapists throughout your recovery to make sure you return to sport not just with a stable knee, but with the strength and confidence to perform at your best."