Were You Told You Need ACL Surgery? The Graft Choice, the Technique, and Whether You Even Need a Full Reconstruction All Matter More Than Most Patients Realize.
An ACL tear is one of the most common serious knee injuries in sports — and one of the most frequently performed operations in orthopedic surgery. Because so many surgeons perform ACL reconstruction, patients often assume the procedure is standardized. It is not.
The graft used to replace the torn ligament, the fixation technique, whether a lateral extra-articular tenodesis should be added, and whether reconstruction is even necessary versus repair — these are genuinely controversial decisions in the current surgical literature, and they are decisions that meaningfully affect your outcome, your recovery, your re-tear risk, and how your knee feels for the rest of your life.
Dr. Raffy Mirzayan has spent 25 years performing ACL surgery and has published extensively on the topic in high-impact peer-reviewed journals. He has moved away from the most commonly used grafts in favor of the quadriceps tendon — a graft he has used exclusively for the past five years with a zero re-tear rate, including in high-level athletes. He performs lateral extra-articular tenodesis when the evidence supports it. And for carefully selected patients with the right MRI findings and ligament quality, he offers primary ACL repair — avoiding reconstruction entirely and preserving the patient's own native ligament.
These are not minor technical variations. They are the decisions that separate good ACL outcomes from exceptional ones.
Call (310) 746-5918 to schedule a consultation. Virtual consultations are available for patients traveling from out of state.
Understanding the Injury: The ACL
The anterior cruciate ligament is the primary stabilizer of the knee against anterior tibial translation and rotatory instability. It runs diagonally through the center of the knee joint, connecting the femur to the tibia, and is critical for the cutting, pivoting, and deceleration movements that define most sports. When it tears — typically from a non-contact pivoting or landing mechanism — the knee loses its primary rotatory stabilizer, producing the instability that makes return to sport unreliable without surgical reconstruction.
ACL tears occur most commonly in athletes between the ages of 15 and 45, with female athletes at significantly higher risk due to differences in lower extremity alignment, neuromuscular control, and hormonal factors. They can also occur in recreational athletes, military personnel, and active adults of any age.
The Graft Decision: Why Dr. Mirzayan Uses the Quadriceps Tendon
Graft choice is the most debated topic in ACL surgery. There are three primary options — bone-patellar tendon-bone, hamstring tendon, and quadriceps tendon — and each has a distinct set of advantages and trade-offs.
Bone-patellar tendon-bone (BPTB) has the longest track record in ACL reconstruction and remains the graft of choice for many professional sports medicine surgeons. Its bone-to-bone healing at both ends of the graft produces reliable fixation, and its track record in high-level athletes is well established. However, it comes with a meaningful set of complications that are not trivial: numbness along the outer aspect of the knee from the infrapatellar branch of the saphenous nerve, anterior knee pain with kneeling and prolonged sitting, and — most significantly — a risk of patellar fracture that persists for up to a year after return to sport. Harvesting a central third of the patellar tendon with bone plugs weakens the patella, and fractures have been reported in athletes who have fully returned to competition.
Hamstring tendon grafts addressed many of the donor site complications of BPTB and became the preferred graft for lower-demand patients. They work well — but in higher-demand athletes, re-tear rates with hamstring grafts are higher than with bone-containing grafts, and graft diameter can be unpredictable.
Quadriceps tendon has emerged over the past decade as the graft that combines the advantages of both without their most significant downsides. It is the largest, strongest tendon graft available for ACL reconstruction — providing abundant graft material with reliable diameter. It can be harvested without a bone block — eliminating the patellar fracture risk entirely — and the harvest site heals with minimal functional consequence compared to patellar tendon harvest. Donor site morbidity is significantly lower than BPTB, and re-tear rates in published series are comparable to or better than BPTB in high-demand athletes.
Dr. Mirzayan switched to the quadriceps tendon exclusively approximately five years ago and has not looked back. In his personal series using this graft — including high-level athletes — his re-tear rate is zero.
Dr. Mirzayan's quadriceps tendon technique — the "Sexy ACL"
The name came from his patients. When athletes compared their post-operative incisions with teammates who had undergone BPTB or hamstring harvest, the reaction was consistent and enthusiastic — the quadriceps tendon incision was dramatically smaller, placed more cosmetically, and healed more favorably than anything they had seen from the other graft options.
Dr. Mirzayan harvests the quadriceps tendon through a horizontal incision over the patella that is approximately 1.5 to 2 centimeters long — oriented along Langer's lines for optimal cosmetic healing. There is no bone block harvest, eliminating patellar fracture risk entirely. The graft is passed and fixed using an all-inside technique with cortical buttons on both the femoral and tibial sides — no large tibial tunnel, no interference screw on the tibial side, and no additional incisions beyond the small harvest site and standard arthroscopic portals.
The result is a reconstruction performed through incisions so small and so well-placed that patients routinely comment on them unprompted — comparing favorably to every other ACL incision they have seen on their teammates.
Lateral Extra-Articular Tenodesis: When and Why
One of the most significant advances in ACL surgery over the past decade is the recognition that intra-articular reconstruction alone does not fully restore rotatory stability in every patient — and that adding a lateral extra-articular tenodesis significantly reduces re-tear rates in high-risk cases.
A lateral extra-articular tenodesis — LET — is a procedure performed through a small additional incision on the outside of the knee that reconstructs the anterolateral ligament and capsular structures, adding a secondary restraint to rotatory instability that the ACL graft alone cannot fully provide. The evidence supporting LET is now substantial, and the downside — a small additional incision and modest additional operative time — is minimal.
Dr. Mirzayan performs LET selectively, in patients where the evidence most strongly supports it: those with high-grade rotatory instability on examination including a high-grade pivot shift, patients with generalized ligamentous hyperlaxity or more than 10 degrees of knee hyperextension, revision ACL cases where a prior reconstruction has failed, and patients with an absent or deficient meniscus that would otherwise leave the knee without its secondary stabilizers.
In these patients, adding LET to the ACL reconstruction meaningfully reduces the risk of re-tear and produces more complete restoration of rotatory stability than reconstruction alone.
ACL Repair: Preserving Your Own Ligament When the Biology Allows
For four to five decades, ACL reconstruction — replacing the torn ligament with a tendon graft — was the universal standard of care. That standard was earned: early attempts at ACL repair in the 1970s and 1980s produced terrible results, because they combined large open incisions, poor suture material, inadequate fixation, and prolonged immobilization in casts. The failure of those early repairs led the entire field to abandon repair in favor of reconstruction.
But those early repairs failed for reasons that have nothing to do with the biology of the ligament itself. They failed because of technique — and technique has changed dramatically.
Approximately ten to fifteen years ago, surgeons began revisiting ACL repair using modern tools: arthroscopic visualization, high-strength suture material, and purpose-built implants that allow the torn ligament stump to be reattached to the femur under appropriate tension without open surgery or cast immobilization. In carefully selected patients — those whose MRI shows a proximal femoral avulsion with good residual tissue quality rather than a shredded mid-substance tear — primary repair produces excellent results, allows faster recovery than reconstruction, and preserves the patient's own native ligament with its proprioceptive nerve endings intact.
Dr. Mirzayan's approach to ACL repair
The decision begins with the MRI. In most ACL tears, the ligament is shredded — there is minimal tissue remaining and no meaningful stump to repair. These patients need reconstruction. But occasionally, the MRI shows a clean proximal avulsion with substantial, healthy-appearing ligament tissue still attached. These are the candidates Dr. Mirzayan considers for repair.
Even then, the final decision is made at arthroscopy. Dr. Mirzayan places the camera in the knee first and directly assesses the ligament. If the tissue is robust, well-vascularized, and of sufficient quality to hold sutures reliably, he proceeds with repair. If it is not — regardless of what the MRI suggested — he proceeds with reconstruction. Every patient consented for repair is also consented and prepared for reconstruction, because that conversion must be available without hesitation.
Over the past five years, Dr. Mirzayan has performed approximately 30 ACL repairs, selecting patients carefully based on these criteria. His revision rate in this series: zero percent.
Published Evidence
Dr. Mirzayan has published extensively on ACL surgery in high-impact peer-reviewed journals. His four major publications on this topic represent contributions across graft selection, technique, and outcomes:
What to Expect: Surgery and Recovery
ACL reconstruction and repair are both performed as outpatient procedures under general anesthesia with a nerve block for postoperative pain control. Patients go home the same day.
For quadriceps tendon reconstruction, the harvest incision is 1.5 to 2 centimeters, horizontal, and placed over the patella. Arthroscopic portals are standard. The all-inside button fixation technique eliminates the need for a large tibial tunnel or additional incisions. When LET is performed simultaneously, a small additional incision is made on the lateral side of the knee.
Recovery follows a progressive rehabilitation protocol. Range of motion is restored in the first weeks under physical therapy guidance. Quadriceps strengthening — particularly important after quadriceps tendon harvest — begins early and progresses systematically. Return to straight-line running typically occurs at 3 to 4 months. Return to cutting and pivoting sports requires clearance based on functional testing and typically occurs between 8 and 10 months. For patients who undergo ACL repair rather than reconstruction, the recovery timeline is generally faster.
Dr. Mirzayan will give you a personalized return-to-sport timeline based on your graft choice, whether LET was performed, your sport, and your rehabilitation progress.
Coming from Las Vegas, Phoenix, Texas, Florida, or Out of State?
ACL surgery is performed at high volumes across the country — but graft choice, technique, the decision to add LET, and the option of repair versus reconstruction are decisions that vary enormously between surgeons and that meaningfully affect long-term outcomes. For athletes who want the most current, evidence-based approach to their ACL — including access to quadriceps tendon reconstruction with zero re-tear rate data, selective LET, and primary repair for appropriate candidates — Dr. Mirzayan offers a level of expertise and a published track record that is worth traveling for.
If you carry a commercial insurance plan — Blue Cross Blue Shield PPO, Aetna, Cigna, United Healthcare, or a self-funded employer plan — you likely have out-of-network benefits that cover a substantial portion of the cost of surgery. His office will verify your coverage before you commit to anything.
Virtual consultations are available. You can submit your MRI in advance, meet Dr. Mirzayan on video, and get a clear assessment of your injury, your graft options, and whether you might be a candidate for repair rather than reconstruction — before committing to travel or time away from sport.
Call (310) 746-5918 or contact us online to schedule your consultation.
Frequently Asked Questions
What is the best graft for ACL reconstruction?
There is no single best graft for every patient — but there is a best graft for each individual patient based on their age, activity level, sport, and anatomy. Dr. Mirzayan uses the quadriceps tendon exclusively for ACL reconstruction, having switched from other graft options approximately five years ago after seeing consistently excellent results — including a zero re-tear rate in his personal series. The quadriceps tendon provides abundant graft material, avoids the patellar fracture risk of bone-patellar tendon-bone harvest, produces significantly less donor site morbidity, and can be harvested through a cosmetically superior incision of 1.5 to 2 centimeters.
What is the "Sexy ACL" and why does it matter?
The nickname came from Dr. Mirzayan's patients — specifically from athletes who compared their post-operative incisions with teammates who had undergone traditional ACL reconstruction. The quadriceps tendon harvest incision Dr. Mirzayan uses is horizontal, 1.5 to 2 centimeters long, placed along Langer's lines over the patella, and heals with a cosmetically superior scar compared to the vertical patellar tendon or hamstring harvest incisions used in traditional reconstruction. Combined with the all-inside button fixation technique — which eliminates the need for a large tibial tunnel or additional incisions — the overall cosmetic and functional result at the harvest site is dramatically better than what most patients have seen on their teammates.
What is a lateral extra-articular tenodesis and do I need one?
A lateral extra-articular tenodesis is an additional procedure performed on the outside of the knee that reconstructs the anterolateral capsular structures and adds a secondary restraint to rotatory instability. It is not needed in every ACL reconstruction — but in patients with high-grade rotatory instability, generalized hyperlaxity, revision cases, or absent meniscus, adding LET significantly reduces re-tear rates and produces more complete stability restoration than intra-articular reconstruction alone. Dr. Mirzayan will assess whether LET is appropriate for your specific situation at the time of your consultation.
Can my ACL be repaired instead of reconstructed?
Possibly — but only in carefully selected cases. Most ACL tears result in a shredded ligament with insufficient tissue remaining for repair. In a subset of patients, the MRI shows a clean proximal avulsion with healthy residual tissue — these are the candidates Dr. Mirzayan considers for repair. The final decision is always made at arthroscopy after direct visualization of the ligament. If the tissue quality is not adequate, reconstruction is performed. Every patient consented for repair is simultaneously prepared for reconstruction. In Dr. Mirzayan's series of approximately 30 ACL repairs over five years, the revision rate is zero percent.
Why did early ACL repairs fail, and why is repair viable now?
The early ACL repairs of the 1970s and 1980s failed because of technique — large open incisions, poor suture material, inadequate fixation, and six weeks of cast immobilization. Those failures had nothing to do with the biology of the ligament. Modern repair uses arthroscopic visualization, high-strength suture material, and purpose-built implants that allow the ligament to be reattached under appropriate tension without open surgery or prolonged immobilization. In carefully selected patients with the right injury pattern, modern repair produces excellent results with faster recovery than reconstruction.
Should I have ACL surgery now or wait until the off-season?
The timing of ACL surgery depends on several factors — the presence of associated injuries such as meniscus tears, the patient's age, sport, and season schedule, and the degree of instability. There is good evidence that delaying surgery until quadriceps strength is restored reduces post-operative stiffness. Dr. Mirzayan will give you a personalized recommendation based on your specific injury, your sport, and your goals.
Do you offer virtual consultations for out-of-state patients?
Yes. You can submit your MRI in advance, meet Dr. Mirzayan on video, and get a clear assessment of your injury and your surgical options — including whether you might be a candidate for repair rather than reconstruction — before committing to travel. Call (310) 746-5918 to schedule.
Does being out-of-network mean I will pay full price out of pocket?
Not necessarily. Many patients with commercial insurance — especially PPO plans and self-funded employer plans — have strong out-of-network benefits. Dr. Mirzayan's office will verify your coverage before your consultation so you have a clear picture of what to expect before making any decisions.
About Dr. Raffy Mirzayan
Dr. Raffy Mirzayan, MD is a double-board certified orthopedic sports medicine surgeon with 25 years of experience performing ACL surgery at every level of competition. He has published four major peer-reviewed papers on ACL reconstruction in high-impact journals, uses the quadriceps tendon exclusively for reconstruction with a zero re-tear rate in his personal series, performs lateral extra-articular tenodesis in appropriately selected patients based on current evidence, and offers primary ACL repair — with a zero revision rate across approximately 30 cases — for patients whose MRI and arthroscopic findings support it. His all-inside quadriceps tendon technique, performed through a cosmetically superior 1.5 to 2 centimeter horizontal incision that his patients have nicknamed the "Sexy ACL," represents the current leading edge of ACL reconstruction. He practices at DOCS Health in Los Angeles, serves as a Clinical Professor of Orthopaedic Surgery at USC, and welcomes patients from across the United States, including Las Vegas, Phoenix, and Scottsdale, for virtual consultations and in-person care.
DOCS Health | 8436 W 3rd St #800, Los Angeles, CA 90048 | (310) 746-5918 | raffymirzayan.com
