Is ACL repair a viable alternative to reconstruction?

Written by Dr Sean Leo, a consultant orthopaedic surgeon whose clinical focus is the knee, sports injuries and the lower limb.

Last updated: 9 October 2026.

ACL repair is a selective option, not a like-for-like alternative to reconstruction. Repair works with the torn ligament itself, while reconstruction replaces it with a graft. Repair is not one operation, and it is not suitable for every tear. Repair can fail and may then require reconstruction.

What is the difference between repair and reconstruction?

ACL repair is a selective option, not a like-for-like alternative to reconstruction. Repair works with the torn ligament itself, while reconstruction replaces it with a graft. The longer-term evidence for repair is limited, and the 2022 American Academy of Orthopaedic Surgeons (AAOS) guideline recommends reconstruction rather than repair when surgery for an ACL tear is indicated. ^[2]

• Reconstruction replaces the torn ACL with a graft. A graft may come from the patient’s own tissue (autograft) or, in selected settings, donor tissue (allograft).
• Repair keeps the torn ligament. One approach places a collagen scaffold between the torn ends in the middle of the ligament, known as bridge-enhanced ACL repair, or BEAR. Another reattaches selected recent tears, typically Sherman type I or II patterns (tears at or very near the ligament’s upper attachment), using sutures and anchor fixation, sometimes protected with suture tape. This only suits tears with adequate tissue quality.
• Repair is not one operation, and it is not suitable for every tear.

More on how the choice is made

A treating surgeon looks at where the tear sits, the quality of the tissue, how recently the injury happened, the person’s age, their activity and any other injuries in the knee. Success with repair depends on factors like these, which is why a general answer about repair cannot say what would suit any one knee.

What does this page cover?

• What is the difference between repair and reconstruction?
• What are the proposed benefits of ACL repair?
• Does ACL repair work as well as reconstruction?
• Can ACL repair fail?
• When should a knee injury be checked urgently?
• What should I ask about at a consultation?

What are the proposed benefits of ACL repair?

The idea behind repair is to keep the person’s own torn ligament rather than replace it. That is why interest in preserving the native ACL has grown, including interest in whether some torn ligaments can heal with the help of a brace.

• In one randomised trial (people assigned to a treatment by chance) of 100 patients aged 13 to 35 (Murray et al., 2020), BEAR met the trial’s prespecified two-year non-inferiority margins, meaning it was not shown to be worse than reconstruction with the patient’s own tendon on a patient-reported knee score and on front-to-back looseness of the knee. ^[3] The patients had a complete tear in the middle of the ligament, were treated within 45 days of injury and had closed growth plates, so the result applies to selected tears and young patients. ^[3] In the same trial, 14% of the BEAR group and 6% of the reconstruction group had a re-injury that needed a second ACL operation, a difference that was not statistically significant in a small trial, and one of the trial’s authors is a founder of the company that makes the scaffold. ^[3] That does not establish that it is better, that it lasts, that it prevents osteoarthritis (wear-and-tear arthritis of the joint), or that it is available locally.
• A separate brace-based approach, the Cross Bracing Protocol, was developed to bring the torn ACL ends closer together during early healing. Its evidence so far is limited and conflicting. A randomised comparison is registered (NCT06956339), so definitive comparative conclusions are not yet available. ^[7]

More on the Cross Bracing Protocol

A later controlled cohort study (Porter and Shadbolt, 2026) of 80 active people aged 16 to 40 who intended to return to pivoting sport compared Cross Bracing with surgical stabilisation at two years. ^[6] Recurrent instability was recorded in 70% of the Cross Bracing group (40 people) and 2.5% of the surgical group (40 people), and a medial meniscal tear (a tear of the cartilage cushion on the inner side of the knee) in 62% and 2.5%. ^[6] Treatment was chosen rather than randomised, and all the patients came from one private practice, so the comparison may be affected by who chose each option. ^[6]

Owner clinical review required · not a release asset

Does ACL repair work as well as reconstruction?

For most tears, that has not been established. Repair is a selective option whose longer-term evidence is limited. The 2022 AAOS guideline recommends reconstruction rather than repair when surgical treatment of an ACL tear is indicated, citing a lower risk of revision. ^[2]

• For proximal suture repair, a 2022 systematic review (a structured summary of earlier studies; Vermeijden et al.) found no randomised studies, an average follow-up of about two years and a weak grade of recommendation. ^[4]
• Newer comparative studies still select people by tear location and tissue quality, so their results apply to selected tears, not to every ACL injury.

More on reading repair evidence

A device manufacturer’s technique page describes a product. It is not evidence that the operation works as well as another.

Can ACL repair fail?

Yes. Repair can fail and may then require reconstruction.

• In the 2022 systematic review of proximal suture repair, the failure rate may have been higher in younger patients, although the estimate was very imprecise. ^[4]
• That finding comes from one type of repair in a group of weaker studies, so it is a caution to discuss with a surgeon, not a prediction for any one person. ^[4]

When should a knee injury be checked urgently?

What should I ask about at a consultation?

This page compares two surgical approaches to ACL tears, but it cannot say which would suit any one knee. An assessment brings together what happened, an examination and any tests that help, so that you and your clinician can decide what to do next. An appointment supports an informed decision. It is not a commitment to surgery.

If you have been told you have an ACL tear, questions worth bringing include:

• Where is my tear, and is the tissue quality suitable for repair?
• How long since my injury, and does that matter for my options?
• Which repair technique would be used, and what is the evidence for it?
• If repair is considered, is that technique available in Singapore?
• If repair fails, what would the next step be?
• How does reconstruction compare for my age and activity?

• Read how the treatment options compare, including repair, on the ACL reconstruction surgery page.
• If you want to understand who repair might suit, see is your ACL injury suitable for repair rather than a replacement.
• Browse the Knee Hub for other knee problems.
• Read about whether a torn ACL can heal without surgery.
• Read about tips for recovering after ACL surgery.
• Read more about Dr Sean Leo, the orthopaedic surgeon who wrote this page.

References

1. American Academy of Orthopaedic Surgeons. Management of Anterior Cruciate Ligament Injuries: Evidence-Based Clinical Practice Guideline. Rosemont (IL): AAOS; published 22 August 2022 (replacing the 2014 edition). Available from: https://www.aaos.org/aclcpg
2. Brophy RH, Lowry KJ. American Academy of Orthopaedic Surgeons Clinical Practice Guideline Summary: Management of Anterior Cruciate Ligament Injuries. J Am Acad Orthop Surg. 2023;31(11):531-537. doi:10.5435/JAAOS-D-22-01020. PMID:36727995. PMCID:PMC10168113.
3. Murray MM, Fleming BC, Badger GJ; BEAR Trial Team. Bridge-Enhanced Anterior Cruciate Ligament Repair Is Not Inferior to Autograft Anterior Cruciate Ligament Reconstruction at 2 Years: Results of a Prospective Randomized Clinical Trial. Am J Sports Med. 2020;48(6):1305-1315. doi:10.1177/0363546520913532. PMID:32298131. PMCID:PMC7227128. Trial registration: NCT02664545.
4. Vermeijden HD, van der List JP, Benner JL, Rademakers MV, Kerkhoffs GMMJ, DiFelice GS. Primary repair with suture augmentation for proximal anterior cruciate ligament tears: A systematic review with meta-analysis. Knee. 2022;38:19-29. doi:10.1016/j.knee.2022.07.001. PMID:35870397.
5. Filbay SR, Dowsett M, Chaker Jomaa M, Rooney J, Sabharwal R, Lucas P, et al. Healing of acute anterior cruciate ligament rupture on MRI and outcomes following non-surgical management with the Cross Bracing Protocol. Br J Sports Med. 2023;57(23):1490-1497. doi:10.1136/bjsports-2023-106931. PMID:37316199. PMCID:PMC10715498.
6. Porter MD, Shadbolt B. Cross Bracing Protocol for Anterior Cruciate Ligament (ACL) Rupture Has Unacceptably High Failure Rate Relative to Surgical Stabilization: A 2-year Controlled Cohort Study. Clin J Sport Med. 2026;36(4):444-450. doi:10.1097/JSM.0000000000001416. PMID:41622530.
7. ClinicalTrials.gov. Cross Bracing Protocol Versus Surgery for Acute Anterior Cruciate Ligament Rupture. Identifier NCT06956339 (recruiting; record checked 5 October 2026). Available from: https://clinicaltrials.gov/study/NCT06956339