*_Howard Luks_, Orthopaedic Surgeon on ACL - _Twittorial_* #ACL surgery remains an imperfect solution to a difficult problem. Too many patients and parents think they or their children will be "normal" after the surgery. There are many decisions we as surgeon make during the surgery. We are still lacking a lot of evidence to guide us ACL injuries risk lifelong knee problems! There is a lot of evidence supporting ACL prevention programs yet very few programs adopt them. The FIFA11 program should be mandatory in kids sports.. From the level of modified through club teams. You tear your ACL... what's next? The injury occurs... what is the best way to determine if the ACL is torn? The exam... Our exam is often more accurate than an MRI in determining if anterior laxity exists. Residents.. examine the postero-lateral corner. Missing that guarantees failure of an ACL reconstruction. So... We do end up proceeding with an MRI. Why? It should not be a surprise to a good examiner that the ACL is torn. We are looking for associated injuries. In particular root tears, and articular cartilage injuries. You hear a lot of Ramp lesions.. I have not found too many. Do all ACL tears require surgery? No. But many children under 18 will go on to develop secondary injuries if treated non-operatively so many of us will recommend surgery for children who participate in Class 1- cutting and pivoting sports. Many adults can get by without ACL surgery. As long as the knee is stable... and they're not rock climbers, roofers, tree surgeons, high-level recreational class 1 sports then a trial of non-op Tx is worth it. Many parents are starting to ask about direct anatomical ACL repairs... actually sewing the torn parts. The research on repairs is not good. So far it appears that 50% + are failing. The BEAR technique may improve those numbers. That study is being conducted now.Time will tell Decision support: Graft choice. Auto versus allograft. Your own vs cadaveric tissue. It's pretty clear we should not be using a cadaver graft in kids. The failure rate is unacceptably high. So-called "hybrid" grafts might be ok.. we don't know yet. The bone patella tendon bone graft is still arguably the gold standard. It has been for decades. It's a longer incision... it hurts more for a week. Then it's all upside. I have been bone grafting the patella defect for decades and do not often see anterior knee pain. The quadriceps tendon is gaining in popularity as a graft choice. A recent paper should give us pause before considering wider adoption -- but more studies are needed. I do like this graft in children and in some revisions. During surgery we need to place tunnels into the bone where your old ACL was. IN the past we put the femoral tunnel away from its normal insertion. Why? Prob to suit our technique. Many of those vertical recons failed. Many didn't. go figure. Many of us have switched over to a more "anatomical" approach. The femoral tunnel has moved down the wall of the notch into the footprint of the ACL. Now some think really low (posterior) tunnels might cause early failure. Again.. it's an imperfect solution. So many surgeons have moved their tunnel to the center of the femoral footprint.. some slightly anterior, proximal part of the footprint. We are not quite sure which spot is perfect. You should be within the footprint. Double-bundle ACL reconstructions became very popular for a while. After all the native ACL has two bundles. But it didn't really decrease the reinjury rate, RTS time frame, etc. So most surgeons perform single bundle ACLR. The tibial tunnel should also in the tibial footprint. More anterior than in decades gone by. Then it was too close to the PCL. That completes an anatomic ACLR. You want to argue all-inside or not? Go for it... it doesn't matter. Securing the grafts in tunnels depends on your graft. For residents... if you don't think it will be easy to remove your fixation in the future then don't use it. Some companies came up with crazy ways to suspend tendons etc. They are very hard to remove and shld not b used Suspensory fixation might stretch. Interference screws for all soft tissue grafts often slip. Interference screws with B-PT-B works well. Keep your eye on that femoral screw. I've seen more than a few exit posteriorly thru the notch :-( Consider using TXA during the surgery. Controls the bleeding really well. These knees do not come back looking huge and ecchymotic. Bone graft the patella. Evolution gave us a 22-25 mm thick patella for a reason. Close the paratenon well. All the research has shown that you do not need a brace. We have used Band-Aids and crutches alone for decades. The dressing influences how your patient feels about the knee. Remember.. recovery from ACL is physical and psych.. less dressing/brace ... then the more certain the patient will feel that the knee is OK. The larger the brace, the bigger the bandage the more worried they are about reinjuring themselves and that can affect their rehab. Give them confidence and a solid recon so they can move fwd with rehab. Start quad sets immediately. Start PT. Research your PT well. MOON or Melbourne protocols are nice because they are milestone based. Time-based progression programs aren't precise enough. Don't rush running... wait until their effusion is gone and the knee is "quiet" Please don't tell your patients they will return to sports in 6 months!! It's not true.. or their knee won't be ready. 10-12 mos is common for many to RTS. Some may take 2 years. Reinjury rates are sky high if they are not ready and RTS too soon. Antero-lateral lig recons. I'm not a big believer in this... yet. Some companies are pushing it hard. Most surgeons who push them might work for that company. Research is sparse and all over the place. Time will tell. The risk of OA increases dramatically after an ACL injury. ACL surgery does not affect that rate. The risk of OA increases even more if there is a meniscus tear. Repair the tears. Most will heal if performed at time of ACLR. Inside-out is back in vogue. It's a solid repair.