When you are diagnosed with an ACL Tear, the volume of information can be overwhelming. Should you choose a Hamstring graft? Is the screw method outdated?

There is a lot of noise in the medical world, but true answers come from medical research data, not opinions. Based on global registries and top-tier medical journals, the most advanced standard of care today is the All-Inside ACL Reconstruction using Quadriceps Tendon, Internal Brace, and LET (Lateral Extra-articular Tenodesis).

In this detailed guide, we break down exactly why this combination is superior to traditional hamstring methods, supported by data from the Swedish Registry, the MOON Group, and studies by experts like Dr. Patrick Smith.

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The 4 Pillars of Advanced ACL Surgery

Dr. Manu Bora’s approach relies on four specific technologies and techniques that differentiate it from standard procedures:

1. Quadriceps Tendon Graft (instead of Hamstring or Patellar).
2. All-Inside Technique (using FlipCutter).
3. Internal Brace (FiberTape augmentation).
4. LET (Lateral Extra-articular Tenodesis).

1. The Graft Choice: Why Quadriceps Tendon is Superior

For years, the Hamstring tendon was the default. However, recent data (Current Reviews in Musculoskeletal Medicine, 2019) reveals significant drawbacks to Hamstring grafts.

• Strength & Stiffness: A native ACL has a stiffness of roughly 242. A Hamstring graft is around 400. The Quadriceps Tendon is significantly stronger with a stiffness of nearly 700. This matches the load demands of high-performance sports better than any other graft.
• Graft Thickness: Size matters. A graft thinner than 8mm has a higher failure rate. Hamstring grafts often yield only 8mm or less (sometimes 7-9mm). The Quadriceps tendon consistently provides a robust 10mm graft, ensuring maximum durability.
• Re-Rupture Rates: The Hamstring tendon has a higher elasticity ("lacking stiffness"), leading to a "bungee cord" effect where the knee feels loose over time. The Quadriceps tendon is stiff and solid, leading to significantly lower re-rupture rates.
• Donor Site Morbidity: While the Patellar tendon is strong, it causes the most kneeling pain. The Quadriceps tendon offers the strength of the Patellar graft with pain levels comparable to the Hamstring the best of both worlds.
• Pro Tip: High-volume surgeons (doing >50 ACLs/year) globally are shifting to Quadriceps tendons because of these superior outcomes.

If you are also suffering from Knee MCL Tear Surgery requirements or complex multi-ligament injuries, the strength of the Quadriceps graft is non-negotiable.

2. The "All Inside" Technique: Less Pain, Better Bone Preservation

Traditional surgery often involves drilling large tunnels through the bone. The All-Inside technique changes this by using a FlipCutter.

• How it works: A pin enters the bone, flips its tip, and drills from the inside out.
• The Benefit: This creates a socket rather than a full tunnel, preserving the outer cortex of the bone.
• The Result: Significantly less post-operative pain and smaller incisions. Dr. Bora uses a QuadPro Harvesterwhich ensures a predictable graft harvest through a tiny incision, minimizing scarring.

This minimally invasive approach is also highly effective for other procedures we perform, such as Knee Meniscus Tear/Injury repair, where preserving tissue is key.

3. The Game Changer: Internal Brace (FiberTape)

This is arguably the most critical advancement for fast recovery. In traditional surgery, the new ligament takes 6 months to biologicalize (become part of the body). During this time, it is weak and vulnerable.

The Internal Brace acts as a "seatbelt" for your new ACL. It is a high-strength suture (FiberTape) that runs alongside the graft.

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• Immediate Protection: It protects the graft from stretching during the healing phase.
• Accelerated Rehab: Because of this protection, patients can often walk without a walker immediately and start bending their knee fully from Day 1.
• Reduced Failure: Research by Dr. Patrick Smith shows an 88% reduction in re-injury rates when an Internal Brace is used.
• No "Creep": It prevents the graft from loosening over time, maintaining that "tight" stable feeling.

This technology isn't just for knees; we also utilize advanced bracing and repair techniques for Ankle Ligament Tear/Injury and Elbow Ligament Tear cases to ensure rapid stability.

4. LET (Lateral Extra-articular Tenodesis)

The ACL rarely tears alone. Often, the Anterolateral Ligament (ALL) on the outside of the knee tears too, causing rotational instability (the knee giving way when pivoting).

• The Problem: Standard MRIs often miss ALL tears. If you fix the ACL but ignore the ALL, the knee will still rotate abnormally, leading to ACL failure.
• The Solution: LET surgery reinforces the outer knee. Combining ACL + LET dramatically reduces the risk of re-rupture and restores full rotational stability, essential for pivoting sports like football, soccer, and combat sports.

This comprehensive approach is vital. Just as we treat Shoulder Dislocation (BANKART Lesion) by addressing the root instability, we must address the rotational instability in the knee.

The Critical Role of Structured Rehab

Surgery is only half the battle. Dr. Bora emphasizes that structured rehabilitation improves strength and recovery by 40-60%.

• Supervised Care: The best outcomes come when the surgeon and physiotherapist work under the same roof.
• Neuro-Muscular Training: Starting this training early (around 3 months) reduces future injury risk by 50%.
• Force Plate Testing: Before returning to sport, objective testing on Force Plates ensures that the injured leg is generating equal force to the healthy leg. "Feeling" strong isn't enough; data must prove it.

Summary: The Advanced ACL Advantage

By combining these technologies, the recovery timeline shifts dramatically:

• Walking: Immediate (vs. weeks on crutches).
• Running: Potential to start in 3 months (vs. 6 months).
• Return to Sport: Safer and stronger return due to preserved muscle mass and the Internal Brace protection.

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Frequently Asked Questions (FAQs)

1. What is the most advanced ACL surgery available today?

he most advanced technique is the All-Inside ACL Reconstruction using a Quadriceps Tendon graft, augmented with an Internal Brace and Lateral Extra-articular Tenodesis (LET).

2. Why is the Quadriceps tendon better than the Hamstring?

The Quadriceps tendon is thicker (10mm vs ~8mm), significantly stiffer (700 stiffness vs ~400), and has lower re-rupture rates compared to Hamstring grafts.

3. Does the Quadriceps graft cause knee pain?

It causes significantly less kneeling pain than a Patellar tendon graft and has comparable low pain levels to a Hamstring graft, making it an ideal choice.

4. What is an Internal Brace in ACL surgery?

It is a strong suture (FiberTape) placed alongside the new ACL graft. It acts as a "seatbelt," protecting the graft while it heals and allowing for accelerated rehabilitation.

5. Can I walk immediately after this surgery?

Yes, thanks to the Internal Brace and strong fixation buttons, most patients can walk without a walker or brace almost immediately after surgery.

6. What is the "All-Inside" technique?

This technique uses special drills (FlipCutters) to create sockets inside the bone rather than full tunnels. This preserves bone stock and significantly reduces post-surgery pain.

7. What is LET (Lateral Extra-articular Tenodesis)?

LET is a procedure to reinforce the Anterolateral Ligament (ALL) on the outside of the knee. It prevents rotational instability and protects the new ACL.

8. Why is LET necessary?

Research shows that adding LET to ACL surgery reduces the failure rate and prevents the "pivot shift" sensation that causes knees to give out during sports.

9. How fast can I return to running?

With the Internal Brace and Quadriceps technique, patients can often begin running at 3 months, compared to the traditional 6-month timeline.

10. Is this surgery suitable for professional athletes?

Yes, this is the preferred method for high-demand athletes (like footballers and combat sports pros) because it offers the highest stability and lowest re-injury risk.

11. Why do Hamstring grafts fail more often?

Hamstring tendons are more elastic and thinner. Over time, they can stretch ("creep"), leading to a loose knee and higher risk of tearing again.

12. What is the "FlipCutter"?

The FlipCutter is a specialized drilling tool that enters the bone as a pin and flips open to drill a socket from the inside out, minimizing trauma to the bone.

13. Does this surgery require a large incision?

No. The QuadPro harvester allows the surgeon to remove the graft through a small incision, and the All-Inside technique uses tiny "keyhole" ports.

14. What is the success rate improvement with Internal Brace?

According to research by Dr. Patrick Smith, the Internal Brace reduces the re-rupture rate by up to 88%.

15. Do I need a brace after surgery?

Because the "Internal Brace" is inside your knee protecting the graft, the need for a bulky external brace is often eliminated or significantly reduced.

16. What is the role of Force Plates in recovery?

Force plates measure the exact ground reaction force of your legs. They are used to objectively confirm that your injured leg is as strong as your non-injured leg before you return to sports.

17. Why is "Supervised Rehab" important?

Studies show that rehab supervised jointly by the surgeon and physio leads to 40-60% better strength outcomes compared to standard physiotherapy.

18. Does the screw loosen in traditional surgery?

In traditional interference screw surgery, the screw can loosen if the knee is moved too early. The All-Inside technique uses adjustable loop buttons which are stronger and allow for immediate range of motion.

19. Is the Quadriceps graft thicker than the Hamstring?

Yes. A Quad graft is predictably around 10mm thick, whereas Hamstring grafts are often unpredictable and can be as thin as 7-8mm.

20. Who is Dr. Manu Bora?

Dr. Manu Bora is an expert ACL surgeon and sports medicine specialist known for utilizing these advanced, evidence-based techniques to treat elite athletes and patients globally.