172: ACL 2.0: Playbook for Reducing Retear Risk

Live from the Arthrex Team Physician Controversies Conference

In this episode of The Sports Docs Podcast, Dr. Ashley Bassett and Dr. Catherine Logan sit down LIVE from the Arthrex Team Physician Controversies with two leading ACL experts—Dr. Pat Smith and Dr. Aaron Krych—to discuss strategies to reduce failure after ACL reconstruction.

The conversation highlights the evolution of ACL surgery, focusing on graft selection, fixation, biologic augmentation, and mechanical protection, with an emphasis on optimizing outcomes in young, high-risk athletes.

Graft: Autograft vs Allograft

Strong evidence shows higher failure rates with allograft in young athletes
MOON data: ~4–6x increased risk of failure in patients <25 years

Allograft best for:

• Older, lower-demand patients
• Revision or multi-ligament cases

Autograft Selection

Graft choice depends on:

• Age, sex, sport, and anatomy

BTB:

• Preferred for high-level pivoting athletes
• Strong fixation, less graft elongation

Quadriceps tendon:

• Increasingly utilized
• Larger graft diameter
• Less donor-site morbidity vs BTB
• Particularly useful in younger and female athletes

Key insight:
Grafts <8 mm are associated with higher failure risk

Internal Brace (IB)

Indications:

• Young athletes
• Hyperlax patients
• Revision ACL

Benefits:

• Decreased graft elongation and cyclic displacement
• Reduced postoperative laxity
• Lower rerupture rates (~1% at 5 years in some studies)
• Faster return to sport and improved rehab confidence

Lateral Extra-Articular Tenodesis (LET)

Strong evidence supports reduced failure rates:

• Primary ACLR: ~11% → 4% (high-risk patients)
• Revision ACLR: ~21% → 5%

Benefits:

• Decreased pivot shift
• Improved return to pre-injury sport
• Cost-effective in high-risk populations

Indications for LET

• Age ≤25 years
• High-grade pivot shift
• Knee hyperextension
• Return to cutting/pivoting sports
• Revision ACL reconstruction

LET Surgical Technique Pearls

IT band graft (7–8 cm x 1 cm)
Passed under or near LCL depending on technique
Fixation near lateral epicondyle

Pearls:

• Fix in neutral rotation and ~30–60° flexion
• Avoid overconstraint
• Close IT band defect

Featured Guests

Dr. Pat Smith – Hospital for Special Surgery Naples

Dr. Aaron Krych – Mayo Clinic, Team Physician for the Minnesota Timberwolves

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Our Hosts:

Catherine Logan, MD, MBA

https://www.cloganmd.com/

Ashley Bassett, MD

https://orthopedicnj.com/physicians/ashley-bassett

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