Tom Melhuish knows the difference between having anterior cruciate ligament (ACL) knee reconstruction surgery versus ACL knee repair surgery.

He’s been unfortunate enough to have had both.

The United Kingdom resident had the former when a defender landed on his knee while he was turning during a soccer match. He tore his ACL, dislocated his knee, and tore his meniscus.

During the reconstructive surgery, doctors replaced his tendon with one from his hamstring. The recovery process took 11 months.

Just a few months after returning to soccer, Melhuish tore the ACL in his reconstructed knee. His doctors simply repaired it. He was back in action 5 months later.

“Reconstruction surgery was far more painful than the repair in terms of recovery,” Melhuish told Healthline. “Knee repair surgery wasn’t as painful and the recovery was much quicker. It was a keyhole surgery that took no longer than an hour.”

Melhuish’s experience lines up with the results of a new study that reports that people who undergo ACL knee repair have better outcomes than people who have ACL knee reconstruction.

The research was presented this week at the American Orthopaedic Society of Sports Medicine 2022 Annual Meeting.

The study hasn’t been peer-reviewed or published yet.

In their study, researchers directly compared the effectiveness of ACL reconstruction with ACL repair after a minimum follow-up of at least two years.

Dr. Adnan Saithna, an orthopedic surgeon and sports medicine specialist in Arizona, and his team compared 75 matched individuals who underwent ACL repair to those who underwent ACL reconstruction during the same period.

ACL reconstruction is a surgical tissue graft replacement of the anterior cruciate ligament to restore its function after an injury. An ACL repair is a minimally invasive procedure to reattach the torn ligament.

Study participants were matched based on several variables, including:

Six months after the operation, researchers used isokinetic testing to assess strength between the knee that had been operated on and the one that had not. During the final follow-up of the study, the researchers measured knee laxity, return to sport, and outcome.

Researchers said the ACL repair group had significantly better recovery in terms of hamstring muscle strength compared to their counterparts who underwent ACL reconstruction.

However, researchers didn’t find a significant difference between the two groups when it came to returning to pre-injury levels in sports. Further, ACL repair was associated with a significantly higher rate of ACL re-rupture, especially in younger age groups.

Dr. Natasha Trentacosta, a pediatric and adult sports medicine specialist and orthopedic surgeon at Cedars-Sinai Kerlan-Jobe Institute in Los Angeles, told Healthline that “saying reconstructing the ACL is more complicated than repairing it is too much of a simplification.”

“We have been reconstructing the ACL more than repairing it for decades for a reason,” Trentacosta said. “Many people have been doing well with reconstructed ACLs. But it is not perfect. This is evidenced by this study which points out increased joint awareness and muscular strength deficits in ACL reconstructions compared to ACL repair.”

“With an ACL repair procedure, we are trying to preserve the native fibers and the original properties of the ligament,” she explained. “Ideally, this will help the knee maintain its proprioceptive properties making the knee feel more natural. By repairing the torn fibers, instead of taking a tendon from somewhere else on the patient, we avoid the morbidity of harvesting a graft from a patient which will lead to weakness in the area.”

“But that doesn’t mean ACL repair is easy,” Trentacosta added. “This is apparent if looking at past literature and research on the subject. It fell out of favor decades ago as a treatment technique because of significantly higher re-rupture rates. However, more recent research in the field has been utilizing ways to enhance and protect the repair technique previously developed using biologic augmentation to decrease re-rupture rates.”

Dr. Alan Beyer, an orthopedic surgeon and executive medical director of Hoag Orthopedic Institute in Southern California, told Healthline said the decision to either reconstruct or repair isn’t simple.

“This study may be a good start, but I am not going to let one study dictate how I approached ACL repair or reconstruction for the last 40 years in practice,” Beyer said. “A lot of the decisions an orthopedic surgeon must make about ACL repair or reconstruction depend on many factors, many of them based on where the tear is located and the age of the patient. That is a decision a surgeon must make based on experience.”

“Anatomy of the injury plays the key role in my surgical decision tree to whether repair or reconstruct,” he added. “Regarding the study, I’d like to know how the outcomes of repair of ACL are five years from now or if there is more risk to associated osteoarthritic conditions down the line.”

Dr. Kevin Stone, an orthopedic surgeon with The Stone Clinic in San Francisco, said patients usually have a choice of which direction to take.

“However, very few ligaments are ideal for repair alone,” he told Healthline. “The most recent articles where collagen scaffold is added to ligament repair have shown those ligaments that are ideal for repair can be repaired but have not shown that ligaments that are not appropriate for repair are not helped by a collagen scaffold.”

“We have a long history of both repair and reconstruction of anterior cruciate ligaments and have found that the best repair is for small partial tear and the best reconstruction is by using a donor of quadricep tissue from a young donor,” Stone noted.

Either way, recovery time is significant and depends on a variety of factors.

“With just an ACL repair or reconstruction, you will likely be on crutches for one to four weeks and then walking with a brace after this for four to six weeks before discontinuing the brace,” said Dr. Mark Sando, a surgeon at Orthopaedic Medical Group of Tampa Bay.

“Your return to sport, however, is likely seven to nine months, or more, away as it takes this long to allow for graft maturation and proper rebuilding of strength and neuromuscular control to protect the healing ligament before returning to play,” he told Healthline.

“This recovery period and postoperative rehabilitation is important and critical for both procedures and does not differ much between the two,” Sando added.

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