ACL Surgery Explained: Graft Choices, New Techniques & Recovery Insights

Medically reviewed by Dr. Sabrina Strickland, MD · Orthopedic Surgeon, Hospital for Special Surgery · Last reviewed: January 22, 2026

Quick Summary

ACL reconstruction restores knee stability after the anterior cruciate ligament tears. Modern graft choices include hamstring tendon, quadriceps tendon, patellar tendon, and the newer BEAR implant; a lateral extra-articular tenodesis (LET) may be added in select high-risk patients to reduce retear. Recovery typically spans 9–12 months with structured rehabilitation, and the right approach depends on age, activity goals, anatomy, and meniscal status.

January 8, 2026

Tearing an Anterior Cruciate Ligament (ACL) is a major event for any athlete or active adult, and the choices made early on, especially those about surgery and graft type, can have lifelong impact. This post walks through how I approach an ACL reconstruction, what graft options mean in practical terms, and how newer techniques may reduce pain and re-injury risk. You can watch the embedded video to hear this explained in more detail and to help you prepare for a conversation with your surgeon.

Who Typically Tears an ACL?

ACL tears are especially common in cutting and pivoting sports, as well as in skiing. The two groups that most often show up in clinic are:

High school and college athletes who play soccer, lacrosse, basketball, and other cutting sports.

Active adults, often between ages 35 and 55, who sustain ACL tears while skiing.

The right treatment plan always starts with understanding a patient’s goals: returning to college-level competition, going back to recreational sports, or simply staying active without instability.

How graft choice is personalized

One of the hardest, and most important, decisions is which graft to use for ACL reconstruction. Common options include quadriceps tendon (quad), hamstring tendon, and patellar tendon autografts.

In my approach to ACL surgery:

I rarely use patellar tendon grafts because the morbidity (what you lose or what hurts after surgery at the harvest site) tends to be too high.

For someone with a smaller quad, a hamstring graft may be preferred, assuming the hamstrings are otherwise healthy.

For a patient with a strong, well-developed quadriceps muscle, a quad tendon graft can be an excellent choice.

Past injuries also matter. For example, if a patient has chronic hamstring issues after a marathon, a hamstring graft is usually not a good option.

Bridge-Enhanced ACL Restoration (BEAR implant) and Lateral Extra-Articular Tenodesis (LET)

In addition to traditional reconstruction, there are techniques that aim to save and repair the existing ACL tissue while supporting it with a collagen scaffold. One such option is Bridge-Enhanced ACL Restoration (often called the BEAR implant), which uses your own tissue and a collagen-based graft to help the torn ACL heal rather than fully replacing it with a tendon from elsewhere.

Another adjunct procedure discussed is lateral extra-articular tenodesis (LET). This additional step:

Adds only about eight minutes to the ACL surgery.

Has been shown to reduce ACL re-injury rates by about 50% in appropriate patients.

These techniques are not for everyone, but they expand the toolbox for tailoring ACL surgery to the individual and their specific injury pattern and risk profile.

Advances in Minimally Invasive ACL Surgery

While the overall concept of ACL reconstruction has been stable, the tools and methods have become more refined over the past decade. For about the last 10 years, the surgery has been performed “all inside,” using specialized drills that curve and allow more precise tunnel placement with smaller incisions.

These advances allow the surgeon to:

Place tunnels more precisely where they should be while being less invasive to bone and soft tissue.

Use shorter grafts and, for hamstring grafts, often take only a single tendon, which can reduce pain and morbidity from graft harvest.

The goal is to restore stability and function while minimizing the collateral damage of surgery itself.

How to Talk with Your Surgeon

Choosing the “best” ACL surgery is not one-size-fits-all. The most important step is an open discussion with your surgeon about:

Your sport, level of play, and long-term goals

Your muscle strengths, previous injuries, and any chronic issues (such as hamstring problems)

Which graft (quad vs hamstring), and whether options like the BEAR implant or LET are appropriate for your specific tear and activity level

Your surgeon should be comfortable with the graft and technique you select together and be able to explain the trade-offs in plain language. Watching the video can help you come to that visit prepared, with better questions and a clearer sense of your priorities.

If you want to see me or get a second opinion, please reach out.

ACL reconstruction, ACL recovery, ACL surgery, ACL tear, athlete knee injury, BEAR implant, Bridge-Enhanced ACL Restoration, graft choice, hamstring graft, knee injury, lateral extra-articular tenodesis, LET procedure, minimally invasive ACL surgery, quad graft, sports medicine

Frequently Asked Questions

How long until I can return to cutting and pivoting sports after ACL reconstruction?

Most patients return to running around 4–6 months and to cutting or pivoting sports at 9–12 months. We use objective testing — quadriceps strength symmetry, hop tests, and movement quality — before clearance, not the calendar alone. Returning too early raises retear risk, so timing is individualized to each patient's progress.

Who is a candidate for the BEAR implant versus a traditional graft?

The BEAR implant suits select acute proximal ACL tears with enough remaining tissue, usually treated within weeks of injury. Chronic tears, distal avulsions, and certain tear patterns still do better with hamstring or quadriceps tendon grafts. Candidacy depends on MRI characteristics, time from injury, age, and activity level — I review each case individually.

When do you add a LET (lateral extra-articular tenodesis) to ACL reconstruction?

I consider adding LET for younger high-risk patients — those returning to pivoting sport, with hyperlaxity, high-grade pivot shift, or revision cases. Adding LET has been shown to reduce graft rerupture in this group, but it isn't needed for every patient. The decision is made together with the patient based on their specific risk profile.