Surgical Considerations
There are several procedures currently used by surgeons to repair the ACL. Surgery involving the medial third of the patellar tendon and the medial hamstring (i.e., semitendinosus) are the two most common procedures.

The Patellar Tendon Graft
This procedure involves taking the middle third of the patellar tendon (autograft) to replace the damaged ACL. The procedure has consistently demonstrated excellent surgical outcomes with a 90 to 95% success rate in individuals returning to pre-injury levels of activity. 

This procedure may not be indicated for people with a history of patellofemoral pain, arthritis, or patellar tendinitis, or for smaller individuals with a narrow patellar tendon. Reported problems with the procedure include post-operative pain behind the kneecap, pain with squatting, and a low risk of patellar fractures.

The healing patellar graft has been linked to anterior knee pain.The prevalence ranges from 15 to 25%, with reported incidences as high as 55%.

The Hamstring Tendon Graft
With this procedure, the surgeon typically harvests strands of tendons from the medial semitendinosus to reconstruct the ACL. This procedure has fewer problems with pain behind the knee-cap, better cosmesis (no anterior incision), decreased post-operative stiffness, and faster recovery. Reported problems with the procedure include increased laxity of the new ligament due to graft elongation (stretching), slower healing of the tendon graft, and loosening of the graft at the anchoring site in the bone. 

The Allograft
Surgeons also use cadaveric or allograft grafts from the Achilles tendon, tibialis anterior, and patellar tendon to replace the torn ACL. The allograft procedure may be beneficial for patients who have failed prior ACL reconstruction or who have multiple ligaments that need repair. Problems with the allograft procedure include risk of infection and graft elongation.

Non-operative Management
Non-operative treatment may be beneficial for older, sedentary individuals, but it may be problematic for younger, active individuals. The ACL-deficient knee may still cause instability with activity and may lead to further injury to knee structures such as the menisci or articular cartilage. The focus of treatment is to maintain adequate ROM, gait, proprioception, and strength of the muscles around the knee specifically, strengthening the hamstrings.

Post-operative Precautions
During the first six to 12 weeks after surgery, the fixation of the graft into the bone is the weakest point. It is common for clients who return to higher-level activity to develop anterior knee pain.

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