Which ACL surgery technique is right for my knee?

What is the best technique for ACL surgery? Single bundle or double bundle, LET or internal brace, Jewel ACL or all inside, does a fancier name mean a better technique? Not at all. Hello friends, my name is Dr Sankalp Pande, and I am a SAFE ACL surgeon.

We Indians also hear some difficult English words that sound very fancy. And then we think, it sounds fantastic, so it must be the best. In ACL surgery, this logic can be dangerous.

Now, a reality check: every name I am about to tell you is an ACL surgery technique or a related method: Single bundle and double bundle ACL reconstruction. LET, whose full form is lateral extra-articular tenodesis. ACL reconstruction with internal bracing. Jewel ACL — a synthetic graft for ACL reconstruction, and all inside ACL reconstruction is a method.

Let us start with the first technique: Single bundle ACL reconstruction. In this, a graft is taken from your own body to make the ACL. In my usual technique, the semitendinosus tendon is taken, and the gracilis can also be added if needed. This graft is placed in the natural position of the ACL.

What is the practical benefit? It is the most widely performed, gold standard technique. In most first-time isolated ACL tears, the results are usually good, and the cost is comparatively normal.

What is the practical drawback? A tendon from your own body is used, so there can be hamstring pain or weakness at first. In a young sports player, a naturally loose joint or a revision patient, additional support may be required. But remember, extra support is not required for everyone.

In double bundle ACL reconstruction, both functional bundles of the ACL are made separately. Some studies show better stability, but the graft, tunnels, implants, cost and complexity all become double compared with single, and a future revision also becomes difficult. It used to be discussed a lot earlier. Nowadays, in routine practice — but it is still used in selected cases.

LET: this is not an ACL replacement technique, extra support is created on the outer side of the knee. Its practical benefit: in young high-risk athletes, or naturally loose joints, or revision surgery, it can reduce graft failure. Practical problem: an extra incision or a bigger cut, besides this, pain on the outer side of the knee, longer surgery and extra cost, and in the wrong patient, over-tightness or stiffness can also happen. In a lower-risk patient, it is unnecessary. So then why shouldn't we do it in every patient? If it is giving extra support anyway? Not at all.

Now let us talk about internal bracing: a strong suture tape is placed along with the ACL graft. This is not a graft, it is extra support. Its practical benefit: the graft can get support during the early healing phase. If the tendon graft is thin, if it is a high-demand sports patient, or a previous failure, where the ACL has already failed, we can consider it.

Practical trouble: extra implant, extra cost, and wrong tensioning can make the knee over-tight. Better results are not guaranteed, and it is not a licence for a faster return to sports either. Why don't we do it in all patients, when it gives extra stability? According to most studies, the long-term results are the same with or without internal bracing.

Now Jewel ACL: this is a polyester-based synthetic scaffold or graft option. It can be used alone or along with a graft from your body. Its practical benefit: when used alone, tendon harvesting can be avoided, and donor-site pain and muscle weakness may be reduced. Its place is in limited tendon availability, selected revision surgery, and multiple ligament injury.

Practical issues: the implant is very costly, and the synthetic material stays in the body permanently. Compared with a tendon graft, strong evidence is not yet available. Rarely, a body reaction can happen. In every patient? Not at all.

Now all inside ACL reconstruction: this is not a graft type, it is a way of making the tunnels, where short sockets are made instead of full bone tunnels. Its practical benefit: less bone is removed, the gracilis can be preserved, in revision surgery this bone preservation is useful, and it can be useful in selected growing teenagers. Practical problems: special instruments, the implant is costlier, and the technique is demanding. In routine knees, a clear advantage over the standard technique is not proven. Smaller sockets alone are not an automatic advantage. In every patient? Not at all.

Now I will tell you the biggest reality, which will really confuse you: single bundle and all inside can be used together, along with that there can be LET or an internal brace, and Jewel ACL can become the graft option. Which is the best technique? In SAFE ACL, we do not declare any one technique the best. Whether one patient needs a procedure or not, in another patient the same procedure may be needed, or may not be. The decision depends on the patient's age, daily activities, sports requirements, joint looseness, whether it is a first or a revision surgery, tendon or graft size, meniscus injury, other ligament injury.

On top of all this, if there is a meniscus repair, the rehabilitation will change, and if there is another ligament injury, the whole surgical plan will change. Surgical technique: clinical examination, MRI, the patient's goal and the surgeon decide together. That is why every patient's surgery plan is not the same. The technique should fit the patient. We do not popularise fancy techniques. We popularise the correct decision.

The best technique is not the one that is the latest. The best technique is not the one that is very expensive either. The best technique is not the one with a fancy name either. The best technique is the one your knee actually needs. Right patient, right technique, right graft, right additional support, right rehabilitation. This is the motto of SAFE ACL.

If ACL surgery is being planned and technique names are confusing you, then send us your MRI reports, call or WhatsApp on the number given on screen or in the description. Don't buy a technique, choose the right plan. Choose SAFE ACL — safer ACL, fit for you, faster and effective. Thank you.