Who Should I See for ACL Reconstruction in Bethesda?

Overview

ACL reconstruction rebuilds a torn anterior cruciate ligament using a tendon graft, most often taken from the patient's own quadriceps or patellar tendon. Dr. Raffo is a high-volume ACL surgeon serving Bethesda, Germantown, and the rest of Montgomery County who selects graft type and whether to add a lateral tenodesis based on age, sport, and knee laxity rather than a single default protocol.

Who this is for

• Patients with a confirmed ACL tear who are active, want to return to pivoting or cutting sport, or have a knee that gives way with daily activity are candidates for reconstruction.
• Younger patients, especially those under 25 returning to competitive pivoting sport, carry a meaningfully higher second-injury rate and are the group where graft choice and adjunct procedures matter most — pooled second ACL injury risk is 21% under age 25 versus 15% overall, rising to 23% in those who return to high-risk cutting sport (Wiggins et al., AJSM 2016).
• Patients who are sedentary, older, have low-demand activity goals, or have significant existing arthritis in the knee are often not good candidates for reconstruction and may do just as well with structured rehabilitation and activity modification; that conversation happens before surgery is scheduled, not after.
• Patients with an isolated partial tear and a stable knee on exam are sometimes managed nonoperatively first — reconstruction is not automatic just because imaging shows a tear.

How I approach it

I don't use one graft for every knee. Quadriceps tendon autograft has become my default for most primary reconstructions because the pooled failure rate in patients 25 and younger is the lowest of the three autograft options in recent meta-analysis, though I tell patients directly that the confidence interval on that number is wide and overlaps with hamstring (Petit et al., AJSM 2026). For high-level contact and collision athletes, and in revision cases, I still reach for bone-patellar tendon-bone. Graft choice is a conversation about the specific patient's sport, age, and tolerance for kneeling discomfort — not a house style I apply uniformly.

I also decide, on a case-by-case basis, whether to add a lateral extra-articular tenodesis. In young, high-risk pivoting athletes I add it far more often than not, because the reduction in graft rupture and rotational failure is large and well-documented. That decision has its own dedicated discussion, because it's the single most consequential judgment call I make on an ACL knee.

The operation

ACL reconstruction is done arthroscopically. The torn ligament remnant is debrided, tunnels are drilled in the femur and tibia to recreate the ACL's native footprint, and a graft — quadriceps tendon, patellar tendon, or occasionally allograft — is passed through the tunnels and fixed under tension. The knee is examined for concomitant meniscus tears before graft fixation, since meniscal injury is present in roughly 4 out of 10 primary ACL reconstructions and is addressed in the same setting whenever possible (Gifstad et al., AJSM 2014). If the knee shows high-grade rotational laxity or other risk factors, a lateral extra-articular tenodesis is performed through a separate small incision at the same setting. The procedure is typically done as same-day surgery.

Risks and honest tradeoffs

• Graft failure and re-tear. Rates vary meaningfully by graft: in patients 25 and younger, hamstring autograft fails in about 11.1%, bone-patellar tendon-bone in 5.1%, and quadriceps tendon in 2.5%, though that last estimate has a wide confidence interval (Petit et al., AJSM 2026).
• Second ACL injury independent of graft. Pooled data show 15% of patients sustain a second ACL injury to either knee, rising to 21% under age 25 and 23% in those returning to high-risk pivoting sport (Wiggins et al., AJSM 2016).
• Post-traumatic osteoarthritis is not prevented by surgery. Roughly 36% of patients have radiographic osteoarthritis at approximately 10 years after ACL reconstruction, and the odds of developing OA after reconstruction are not lower than after the injury itself managed without surgery (OR 7.7 vs 6.81) (Webster & Hewett, Clin J Sport Med 2022). Meniscal status is a major driver — reported OA prognosis is 0–13% without meniscus injury versus 21–48% with it (Grindem et al., BJSM 2016).
• Anterior knee pain and kneeling discomfort depend on graft choice: bone-patellar tendon-bone carries roughly triple the risk of severe kneeling difficulty compared with hamstring graft (21.3% vs 9.4%), though constant knee pain does not differ between the two (9.9% vs 9.2%) (Rahardja et al., AJSM 2023).
• Quadriceps strength recovery is slow. On average, quadriceps strength reaches only about 76% of the uninjured leg at 6 months and roughly 85% at 1 year, not approaching 90% until close to 5 years — below the symmetry threshold commonly used to clear return to sport (Girdwood et al., BJSM 2025).

Recovery and rehabilitation

Recovery follows a criteria-based, not purely calendar-based, protocol. Early motion and early weightbearing are encouraged from the first days after surgery, since mobilizing early does not compromise graft stability and reduces patellofemoral pain (Kotsifaki et al., BJSM 2023). Running is typically permitted around 8 to 16 postoperative weeks once pain, motion, and strength benchmarks are met, rather than on a fixed calendar date (Rambaud et al., BJSM 2018). Return to cutting and pivoting sport is not cleared before 9 months, because reinjury risk falls with each additional month of delay up to that point, with no further benefit from waiting longer (Grindem et al., BJSM 2016).

• Weeks 0–2: Active and early weightbearing motion started immediately; focus on reducing swelling and regaining extension.
• Weeks 3–6: Progressive closed-chain quadriceps strengthening; open-chain quadriceps exercise is avoided in this window.
• Weeks 8–16: Return to running once pain, motion, and strength criteria are met, typically at 8 to 10 km/h.
• Months 6–9: Sport-specific agility and cutting drills; formal strength and hop testing begins.
• Month 9 and beyond: Return to pivoting and contact sport only after passing a strength and hop-test battery, not by calendar date alone.

1. Weeks 0–2

   Active and early weightbearing motion started immediately; focus on reducing swelling and regaining extension.

2. Weeks 3–6

   Progressive closed-chain quadriceps strengthening; open-chain quadriceps exercise is avoided in this window.

3. Weeks 8–16

   Return to running once pain, motion, and strength criteria are met, typically at 8 to 10 km/h.

4. Months 6–9

   Sport-specific agility and cutting drills; formal strength and hop testing begins.

5. Month 9 and beyond

   Return to pivoting and contact sport only after passing a strength and hop-test battery, not by calendar date alone.

Alternatives I considered

For a narrow group of patients — a complete midsubstance or proximal tear with at least half the ACL's length still attached to the tibia on MRI, seen within about 45 to 50 days of injury — I discuss bridge-enhanced ACL restoration (BEAR) as an alternative to reconstruction. It met noninferiority for subjective and laxity outcomes at 2 years in a randomized trial, but the raw graft conversion/failure rate was higher than reconstruction in that same trial (14% vs 6%), and the aggregate re-tear rate across BEAR studies is around 15% (Murray et al., AJSM 2020; Shah et al., 2025). AAOS still gives a strong recommendation for reconstruction over repair in surgical candidates (AAOS ACL CPG, 2022), and I reserve BEAR discussion for patients who meet the narrow eligibility window and want to preserve their own ligament.