“Patellar tendon is the gold standard”—or is it?

I recently saw a 48-year-old in my office who tore his ACL skiing. He is very active, participating in both winter and racket sports, and wants to return to that level. He had already seen a colleague who told him that he had to undergo a patellar tendon autograft ACL reconstruction because this is the “gold standard.” He came to see me for a second opinion, wanting to discuss whether there were any other options, since none had been offered to him.

This is not a unique example. In fact, it happens often enough that I felt it was worth writing about.

First off, there is no such thing as a “gold standard” in ACL reconstruction. Like most things in medicine, the choice of graft depends on who you are and what you want to do. Some surgeons, however, seem to forget this, and in their eyes the choice becomes more about what they are comfortable with than what is best for the patient.

There is a recent publication (link here) in the American Journal of Sports Medicine from the Swedish Knee Ligament Registry that speaks directly to this issue. What is particularly valuable about these registry studies, especially those from Scandinavia, is that every single surgery is entered and followed. This removes many of the biases related to individual surgeon skill, preference, and belief, and provides a more honest picture of outcomes across an entire population—young and old, active and sedentary.

This particular study reported on failure rates in over 44,000 patients who underwent ACL reconstruction using either quadriceps tendon, patellar tendon, or hamstring tendon autografts. A subset of approximately 19,000 of these patients also had patient-reported outcome scores available. These scores reflect how patients perceive their activity level, pain, and overall function in daily life and sports.

What was fascinating about this study was that patients who underwent quadriceps or hamstring tendon grafts were more likely to achieve an outcome that they considered satisfactory compared to those who had a patellar tendon graft—the so-called “gold standard.” At the same time, there were no meaningful differences in failure rates between the three graft types, all of which were below 3%.

If there is little to no difference in failure rates, then the logical next step is to choose the graft that causes the least long-term problems.

A study from Hospital for Special Surgery (link here) that analyzed 21 randomized controlled trials with more than 1700 patients comparing the same graft types found a 69% lower chance of donor-site morbidity—meaning problems related to where the graft is taken from—with hamstring or quadriceps grafts compared to patellar tendon autografts.

Another study (link here) showed that persistent and severe kneeling pain was three times more likely with patellar tendon grafts than with hamstring grafts.

Yet another analysis of 12 randomized controlled trials (link here) involving more than 1,400 patients demonstrated that while there were no differences in stability or graft failure, there were significant differences in anterior knee pain, kneeling pain, and the development of osteoarthritis, all of which were higher in patients who had patellar tendon grafts.

So while there may be differences in certain subgroups, particularly in very young patients, for my 48-year-old patient there are no meaningful differences in failure rates between graft types. Given that, I recommended choosing the option with the lowest risk of long-term problems, which in his case was a hamstring autograft.

And as for those very young patients, even there the story is not so simple. A study comparing patellar tendon reconstruction to the technique I prefer for these patients - hamstring autograft combined with a lateral extra-articular tenodesis - showed that the patellar tendon group had a fourfold higher failure rate.

I try to find the right balance between risk and reward for each individual patient, and that balance depends on who you are and what you want to return to. For that reason, I do not think I have ever used the term “gold standard.”

Why "It Depends" may be the best thing to hear from a surgeon.

Today I want to talk a little bit about treatment options. Sometimes the best answer you can get from a physician—or from a surgeon, in my case—is actually, “it depends.”

And why is that? Because it means there are multiple possible options. If there were only one option, you would simply be presented with that single solution. But most conditions, especially in orthopaedics, allow for several different approaches.

I see many patients who come to me for a second opinion. Often they have seen another surgeon who gave them just one answer. For example, someone may come in with knee arthritis and say, “The other surgeon told me I need a knee replacement.” Or they were told, “You will need a knee replacement eventually, but you’re not ready yet—so just wait until you’re older and the pain becomes unbearable.”

In many situations, my answer is different. My answer is usually, it depends.

That’s because the right treatment depends on several factors: how much pain you have, how much damage is present in the knee, and exactly where that damage is located.

If someone truly has severe arthritis throughout the entire knee—what we call “bone-on-bone” arthritis everywhere—then a total knee replacement may indeed be the best solution if the pain is significant enough. But if the pain is manageable, there are still many non-surgical options we can try first. These might include injections such as hyaluronic acid, PRP, or occasionally cortisone for flare-ups. Physical therapy, bracing, and oral supplements like turmeric, glucosamine, vitamin E, or fish oil can sometimes help as well. Even medications like Advil or Aleve may provide relief.

But many patients I see don’t actually have bone-on-bone arthritis everywhere. Sometimes the arthritis is limited to just one part of the knee—for example, the medial compartment, which is the inside part of the joint.

In those cases, the answer shouldn’t automatically be a total knee replacement. Instead, the treatment options may range from doing very little to considering several different interventions.

If symptoms are mild, sometimes the best approach is simply to listen to your body and continue your normal activities without aggressive treatment.

If symptoms are more bothersome, we might consider supplements or medications, injections, or supportive treatments such as a medial unloading brace.

And sometimes surgery becomes an option—but even then, there are several possibilities depending on the specific situation. In certain cases, we may consider cartilage repair if the problem is more of a focal cartilage defect. In other cases, especially if someone is bow-legged and placing excessive pressure on the inside of the knee, a procedure called a high tibial osteotomy may be appropriate to realign the leg and unload that compartment.

There are also newer technologies such as the MISHA implant—an implanted shock absorber designed to reduce pressure in the medial compartment of the knee.

And in some patients, a partial knee replacement—also called a unicompartmental knee replacement—may be the best surgical solution if the arthritis is limited to just one area.

So as you can see, there are many possible approaches. The right one depends on your individual situation—how much pain you have, how much damage is present, and what your goals are.

To determine that, we rely on good imaging studies such as X-rays, alignment views, and MRI scans, along with a careful physical examination. Then we can sit down together, review the findings, and decide which treatment option—or options—make the most sense for you.

Do I need surgery for my unstable patella?

One of the most common and most important questions my patients ask when they come in with patellar instability is: Do I need surgery, or can I manage this without it?

In a recent issue of the American Journal of Sports Medicine (AJSM), a high-quality systematic review and meta-analysis directly addressed this question. (Article Link) The senior author was Justin Mistovich from University Hospitals in Cleveland. The authors analyzed randomized controlled trials comparing three treatment approaches:

1. Non-operative treatment

2. MPFL repair (an older surgical technique)

3. MPFL reconstruction (the modern surgical standard)

The differences were striking.

• Non-operative treatment had a recurrent dislocation rate of a little over 30%.

• MPFL repair reduced that risk to about 15%.

• MPFL reconstruction lowered the recurrence rate to just 4%.

In other words, modern MPFL reconstruction reduces the risk of another dislocation from roughly one in three down to about one in twenty-five.

That difference matters. I have seen many patients who experienced several dislocations without major cartilage injury—until one particularly severe, unpredictable event caused significant cartilage damage. Once that happens, long-term outcomes can change dramatically.

Because of this, I now emphasize two key principles in my practice. First, I carefully evaluate each patient’s anatomic risk factors—such as patella alta, trochlear dysplasia, an elevated TT–TG distance, age, and other structural features—to estimate how likely recurrence is. Second, we use that information for shared decision-making, weighing the risk of recurrence against the risks and benefits of surgery.

Patellar instability should not simply be dismissed with a quick physical therapy prescription and no deeper discussion. The recurrence risk can be substantial, and modern surgical techniques are highly effective when appropriately indicated.

The second important question patients often ask—especially after undergoing surgery on one knee—is:

If this happened on one side, is it going to happen on the other? Should I consider doing something prophylactically?

Another study in the same AJSM issue, led by Chital Parikh at Cincinnati Children’s Hospital Medical Center, examined this exact issue. (Article Link) The authors reviewed all MPFL reconstructions performed at their institution between 2012 and 2022 to determine the likelihood of a contralateral (opposite-side) dislocation.

Patellofemoral instability is often related to how someone is built. Structural factors such as:

• Patella alta

• Trochlear dysplasia

• Elevated TT–TG distance

• Younger age

• Female sex

all increase susceptibility to dislocation.

The findings were highly informative:

• If a patient had none of these anatomic risk factors, the risk of dislocation in the opposite knee was less than 10%.

• If a patient had all of these risk factors, the risk rose dramatically—approaching 80%.

That is an enormous difference.

For families, this data provides clarity. If the risk of the other knee dislocating is close to 80%, a discussion about prophylactic stabilization becomes very reasonable. If the risk is under 10%, surgery on the opposite side is likely unnecessary.

Taken together, these two studies reinforce an important message:

Patellar instability is not a one-size-fits-all condition. With careful evaluation of individual anatomy and evidence-based discussion of recurrence risk, we can make thoughtful, personalized decisions about whether surgery is appropriate—and when it may prevent significant long-term damage.

Rethinking Post-Operative Pain Management: A Multimodal Approach

One of the most frequent concerns that comes up during surgical planning—particularly when we discuss the post-operative period—is pain management. Patients are understandably worried about pain medications, especially narcotics. This is a very valid concern.

Over the years, I have adjusted my post-operative recommendations with one primary goal in mind: minimizing the use of narcotics while still keeping patients comfortable and allowing them to recover effectively. To accomplish this, I use what is called a multimodal pain management regimen. This means we rely on multiple strategies—both physical measures and medications—rather than depending heavily on a single drug.

Swelling Control: The Foundation of Pain Control

Pain control actually begins before we even talk about medications.

One of the most important post-operative strategies—especially for lower extremity procedures—is elevation. Swelling creates pain. It also slows down rehabilitation because it interferes with joint motion and can even temporarily shut down muscle activation. Anything we can do to minimize swelling helps reduce pain and accelerates recovery.

Another critical component is icing.

In the past, patients commonly used ice packs directly from the freezer. However, these can be quite dangerous. They are extremely cold and should never be placed directly on the skin. They must be removed after about 20 minutes to allow the skin to recover. It is especially important never to fall asleep with a traditional ice pack on the skin, as frostbite can occur.

For these reasons, I now frequently recommend specialized cold-therapy devices. The two machines I most commonly use are Game Ready and NICE.

The latest versions of these machines do not require traditional ice. They function almost like a small refrigerator, cooling water internally and circulating it through a wrap. Because the temperature is controlled and not as extreme as freezer ice, the risk of skin injury or frostbite is significantly reduced.

In addition to cold therapy, these machines can also provide compression. I typically recommend starting compression a few days after surgery, once the incisional pain has begun to settle. When introduced at the right time, compression can be extremely helpful in controlling swelling. Reduced swelling not only improves comfort but also supports better motion and muscle activation during rehabilitation.

Many of these devices also have built-in programs that automatically cycle on and off every 20–30 minutes. As long as they are used appropriately, patients can safely run them for extended periods—even hours at a time—which I have found to be extremely helpful for managing both pain and swelling.

Multimodal Medication Strategy

In addition to physical measures such as elevation and icing, I use a multimodal medication approach.

One helpful strategy is to use several different medications at appropriate doses rather than relying on a high dose of a single medication. At first, this can feel overwhelming because it may involve taking multiple pills. However, this approach allows us to target pain through different mechanisms while minimizing side effects.

For example:

• Acetaminophen (Tylenol) is tried and true. On its own, it is not particularly strong, but it has very few side effects—provided patients are careful not to exceed the maximum daily dose.

• I often prescribe an anti-inflammatory medication. Frequently, I use Celecoxib, which is a selective anti-inflammatory that does not significantly interfere with bleeding—an important consideration in the post-operative setting.

• I may also prescribe Gabapentin. Originally developed for neurological conditions, it has been found to help with nerve-related pain and can reduce the overall need for narcotics.

• There is also a newer, non-narcotic pain medication that was recently FDA-approved called Journavx. We have started incorporating this into our pain protocols as well, although some insurance companies do not yet cover it.

Narcotics: Reserved as a Last Resort

For more painful procedures, I still prescribe Oxycodone, but in small quantities. I view narcotics as a medication of last resort, intended primarily for the first few days after surgery if pain is not adequately controlled by the other components of the regimen.

The goal is not to eliminate pain entirely—that is often unrealistic—but to make it manageable while minimizing risks and side effects.

Lindsey Vonn races with an artificial knee. So why bother keeping your own?

Here’s another (at least vaguely) ski-injury–related topic. By now, most people know that Lindsey Vonn tore her ACL — but that’s not really what I want to focus on. What her story reminds me of is that she’s a great example for discussing joint preservation versus joint replacement. A few years ago, she underwent a partial knee replacement, and it clearly worked remarkably well — she even returned to Olympic competition. That’s essentially unprecedented.

So that raises a question: Why don’t we always replace knees? Why do we bother with cartilage transplants, meniscus transplants, or osteotomies, which often involve a more demanding recovery?

The reason is that a mechanical solution like a joint replacement limits future options. If you’ve had a replacement, I can usually predict your next surgery — it will be another replacement, typically a larger or more complex one. You move from partial to total, from total to revision total. And revision surgeries generally don’t perform as well as primary replacements. Each step tends to become more complicated, and outcomes may decline over time.

If you begin this process in your 50s or 60s, that progression is often acceptable. For example, you might start with a partial replacement, keep it into your mid-60s, then transition to a total replacement and do well long-term. But if you start in your 20s, you could face three or four revision surgeries over your lifetime — and that’s far less ideal.

That’s where joint preservation comes in. These procedures act as a bridge. I can’t promise that an osteotomy or cartilage procedure in your 20s means you’ll never need further surgery — in fact, you probably will. And you may ultimately require a knee replacement. But the goal is to delay that step. You start the replacement “clock” later in life, when the number of revisions needed is likely smaller.

Another advantage of joint preservation is flexibility. Unlike replacement, it doesn’t burn bridges or limit future choices. Your next step could be anything — an injection, a biologic therapy, a medication, or perhaps a next-generation replacement that’s significantly improved compared to what’s available today. Even delaying replacement by 10–15 years means benefiting from advances in implant design and surgical technique.

That’s the value of joint preservation: managing symptoms, maintaining activity, and buying time — allowing you to take advantage of future innovations while postponing irreversible mechanical solutions.

Thanks very much.

Lindsey Vonn competes with a torn ACL. Why that may work for some.

Anyone with even the faintest interest in winter sports has likely heard about Lindsey Vonn’s ACL injury. What’s remarkable is that she has said she’ll attempt to compete in the Olympics with a torn ACL. That often surprises people — I hear from friends and patients all the time — because the common assumption is that if you tear your ACL, reconstruction is mandatory.

She’s a very special case. So let’s talk more generally, about typical patients. It’s not necessarily true that you must have your ACL reconstructed. The primary reason we consider ACL reconstruction is to restore stability to the knee — and stability matters for several reasons.

In the short term, most people simply don’t like the uncertainty of an unstable knee. Pivoting or twisting activities — soccer, tennis, pickleball — or even everyday situations like navigating a crowded sidewalk and changing direction quickly can lead to buckling. That unpredictability affects quality of life and confidence, and reconstruction can allow people to return to the sports and activities that are part of their social and physical routine.

There’s also a joint-preservation aspect. An unstable knee that buckles repeatedly places the meniscus at risk. I often compare it to jumping a curb with your car — each impact increases the chance of damaging the tire. Similarly, each episode of knee instability increases the risk of meniscal injury or further damage. And meniscal health plays a major role in the long-term development of arthritis. If your meniscus is intact, preserving it is valuable — and you’re more likely to preserve it with a stable knee.

On the other hand, if you don’t participate in higher-risk activities — perhaps you prefer cycling or other low-impact exercise — and especially if you’re older or have a partial tear, non-operative treatment may be reasonable to consider.

But if you’re younger, want to return to cutting or pivoting sports, and your meniscus is still intact at the time of injury, my general recommendation is to restore as much stability to the knee as possible — both for current function and long-term joint health.