Tyler J. Nathe
ACL Repair & ReconstructionTreatment Information
The ACL is a crucial ligament located in the center of your knee, providing essential rotational stability during activities that involve cutting, twisting, and pivoting.
ACL Treatment Videos
Choosing the Best ACL Surgery For You
Dr. Nathe has performed over 1100 ACL reconstruction surgeries and is experienced in all techniques. He tailors his approach to what is best for the individual patient.
The ACL is a crucial ligament located in the center of your knee, providing essential rotational stability during activities that involve cutting, twisting, and pivoting. In cases where there is no accompanying meniscus damage, one treatment option is physical therapy combined with lifestyle modifications. Many individuals, after completing a comprehensive rehabilitation program, can successfully return to activities like cycling, walking, and light jogging even with an ACL-deficient knee.
However, if your goal is to return to sports that involve pivoting, jumping, or skiing, then ACL surgery is often recommended. This procedure aims to restore stability to your knee, preventing recurrent instability and buckling that can lead to further damage within the joint.
Dr. Nathe will carefully evaluate your individual circumstances, including your activity level, desired outcomes, and any other knee injuries, to determine if ACL surgery is the right choice for you.
For ACL (anterior cruciate ligament) surgery, we perform an anatomic reconstruction of the ligament. That is, we replace the damaged tissue with new tissue.
There are several options to choose from for a graft to replace your ACL. The ACL is reconstructed with a tendon, and over time your body grows blood vessels into that tendon and remodels the tendon into a new ligament. This process is called “ligamentization” and takes approximately 9-12 months.
BEAR Implant (Bridge-Enhanced ACL Repair)
Alternatively, we can preserve the anatomy of the knee without harvesting a graft with a new technique, ACL repair with BEAR. This is a newer technique that involves repairing your existing ACL rather than replacing it with a graft. A special implant is used to help the torn ligament heal back together.
- Advantages: May preserve more of your natural knee anatomy and function, potentially lower risk of arthritis long-term, faster return of muscle strength, potential to preserve proprioception of the knee, and higher satisfaction. No risk of donor site morbidity from harvested graft.
- Disadvantages: This is a newer technique with less long-term data available. It is currently best suited for a specific type of ACL tear (proximal tears). Studies have shown a noninferior retear rate compared to hamstring autografts. Given “noninferior” retear rate to hamstring this technique is currently best suited for lower risk individuals.
Allograft vs. Autograft
Autografts
If you decide to use an autograft, there are three options: Patellar, Hamstring, and Quadriceps Tendons.
Patellar Tendon: The gold standard. The best option for young athletes with closed growth plates. The middle 1/3rd of the patellar tendon with a piece of bone from the kneecap and a piece of bone from the patellar tendon insertion on the tibia (bone-tendon-bone).
- Advantages: Strong graft, good fixation, lower risk of failure than hamstring in young athletes, risk of failure is 2.1 higher for hamstring than patellar tendon autograft in high school and college age athletes. Lowest risk of failure and need for revision.
- Disadvantages: risk of kneeling pain, small patch of numb skin to the outside of the incision, risk of patellar tendinitis pain that is rare, very rare chance of patellar tendon rupture or patella fracture. The hardest to rehab of all the options.
Hamstring Tendons: This is a great option for recreational athletes 30 and above. Two of the hamstring tendons at the back of the thigh are used. They are harvested through a 2.5 to 3 cm incision on the front of the shin bone just below the knee.
- Advantages: Smaller scar, less postoperative pain, easier recovery in the first few months. Lowest risk of donor site morbidity (pain and weakness) of the autograft options. On average 20% hamstring weakness long term. Equal risk of retear to other autograft options in patients age 30 and above. Easiest rehab of the autograft options.
- Disadvantages: Higher retear rate than patellar tendon autograft in ages 15-25 (approximately 12% vs. 5% according to the MOON study), the potential for hamstring weakness, chronic hamstring pulls (rare). Similar rate of retear.
Quadriceps Tendon: This is a great graft for high-risk athletes. Used when the patellar tendon is not an option, such as open growth plates or in revisions when the patellar tendon has been used previously. A portion of the quadriceps tendon (the tendon connecting your thigh muscles to your kneecap) is used.
- Advantages: Strong graft, potentially less anterior knee pain compared to the patellar tendon, low risk of failure and need for revision.
- Disadvantages: May have a slightly higher risk of complications such as tendonitis or weakness in knee extension. On average 20% quadriceps weakness long term. This option is newer, and we do not fully understand the long-term risks later in life.
Allografts
This is a good option for those age 45 and above as the risk of retear is very low for both allograft and autograft options. Early recovery is easier as there is no donor site pain or weakness from the autograft harvest site.
- Advantages: No donor site pain and weakness. Early rehab and recovery are easier
- Disadvantages: Higher risk of failure or retear in younger people. Not a good option for those under age 40 due to retear risk. Very remote chance of disease transmission.
Lateral Extra-Articular Tenodesis (LET)
In some cases, Dr. Nathe may recommend a procedure called lateral extra-articular tenodesis (LET) in addition to ACL reconstruction.
LET involves reinforcing the outside of your knee with a portion of your iliotibial (IT) band. This can help to improve stability, especially for patients who have a higher risk of re-tear or those who participate in high-pivot sports.
LET with IT band autograft has shown a risk of re-tear from 11% to 4% for ACL reconstruction with hamstring autograft in patients under 25 years of age.
Dr. Nathe will recommend adding this to reinforce the ACL reconstruction in high-risk athletes. Some of these risk factors include very young age, significant knee hyperextension at baseline, high risk sports, and strong family history of ALC injuries.
Making the Decision
The best graft choice for you will depend on several factors, including your age, activity level, tear pattern, and individual preferences. We will discuss these factors together and determine the best option for your specific needs.
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Treatment Information
Click a category below to learn more about Dr. Nathe’s approach to the common injuries he treats.
ACL Repair & Reconstruction
Knee Replacement
Knee Arthroscopy & Meniscus Surgery
Shoulder Care
Platelet Rich Plasma (PRP)
