Yes, ACL surgery is almost always performed arthroscopically. Arthroscopic ACL reconstruction is the gold standard treatment for a torn anterior cruciate ligament, and it has been for decades. Open surgery, which required a large incision and full exposure of the knee joint, is rarely performed today. The arthroscopic approach uses a few small incisions, a tiny camera, and specialized instruments to complete the entire reconstruction from inside the knee.
What “Arthroscopic” Actually Means
An arthroscope is a small tube containing a miniature video camera, a light source, and a system of lenses. Your surgeon inserts it through a small portal (incision) near your knee, and it streams a magnified, real-time image of the inside of your joint to a monitor. Additional portals allow the surgeon to pass in cutting, grasping, and drilling tools. Most ACL reconstructions use a three-portal technique: typically one on the outer side of the knee, one on the inner side, and one on the upper shinbone where the new graft is threaded through.
Because the instruments and camera go inside the joint rather than opening it up, the surrounding muscles, tendons, and skin sustain far less damage than they would with traditional open surgery. That translates to less post-operative pain, less swelling, and a faster start to rehabilitation.
How the Surgery Works
After you receive anesthesia (usually spinal), the surgeon first examines the knee under anesthesia to check for any additional injuries to cartilage or other ligaments. You’re positioned on your back with a tourniquet on your thigh to control bleeding.
The arthroscope goes in through the first portal, giving the surgeon a clear view of the torn ACL and the rest of the joint. Through the other portals, the surgeon cleans out the remnants of the damaged ligament, then drills small tunnels into the thighbone (femur) and shinbone (tibia). These tunnels are precisely placed to match where the original ACL attached. A replacement graft is threaded through the tunnels and secured on both ends with fixation devices, essentially anchoring the new ligament in place so it can heal into the bone over time.
An arthroscopic shaver removes any remaining tissue debris before the portals are closed with sutures. The entire procedure typically takes one to two hours.
Types of Grafts Used
The graft that replaces your torn ACL is the most important variable in the surgery, and your surgeon will discuss options based on your age, activity level, and goals. The two broad categories are autografts (tissue taken from your own body) and allografts (donor tissue).
Patellar tendon autografts, taken from the tendon connecting your kneecap to your shinbone, have the lowest failure rates at 2% to 6% and the highest return-to-sport rate at roughly 81%. The tradeoff is a higher chance of anterior knee pain at the harvest site. Quadriceps tendon autografts are a newer option showing similarly low failure rates of 2% to 3%, good stability, and less discomfort at the donor site, though long-term data is still limited. Hamstring tendon autografts are commonly used and cause less knee pain, but they carry higher failure rates of 11% to 17% and a lower return-to-sport rate around 52%.
Allografts, where the tissue comes from a cadaver donor, avoid the need for a second harvest site on your own body. However, they carry higher failure rates (6% to nearly 14% depending on tissue type), particularly in younger, more active patients. For high-demand athletes, patellar tendon or quadriceps tendon autografts generally offer the best combination of durability and function.
Recovery Timeline
Recovery from arthroscopic ACL reconstruction follows a structured, phased approach. While every person heals differently, the milestones are well established.
Weeks 0 to 6: Early Phase
The priority is reducing pain and swelling while gradually restoring range of motion. You’ll work on bending and straightening the knee and begin gentle quadriceps strengthening, sometimes with the help of electrical muscle stimulation. Most people use crutches during this period and may wear a brace.
Weeks 7 to 9: Intermediate Phase
You can enter this phase once your knee bends to about 115 degrees, swelling is minimal, and you’re walking with a normal gait. Balance exercises, neuromuscular training, and light aerobic activity begin here. The goal is full, symmetrical range of motion in both knees.
Weeks 10 to 16: Late Phase
Running is introduced once your quadriceps strength in the surgical leg reaches at least 80% of your other leg. You’ll also begin landing mechanics training and transition into more intensive gym-based strength work.
Months 4 to 6: Transitional Phase
Jumping, sprinting, decelerating, and agility drills enter the program. Strength and hop testing should reach at least 85% symmetry between legs before progressing further.
Months 6 to 12: Return to Sport
Sport-specific drills and conditioning ramp up during this window. Full clearance for competition requires no pain or swelling, quadriceps strength and hop test scores at 90% or greater compared to the other leg, and adequate psychological readiness, meaning confidence in the knee and low fear of re-injury. Many athletes return to full competition between 9 and 12 months, though some need longer.
Why Arthroscopic Replaced Open Surgery
Before arthroscopy became widespread, ACL reconstruction required a large incision that opened the entire knee joint. This caused significantly more tissue damage, longer hospital stays, and a slower, more painful recovery. The arthroscopic approach dramatically reduced all of these problems. Because the camera provides a magnified, well-lit view of the joint interior, surgeons can actually see structures more clearly than they could during open surgery, improving precision when placing tunnels and securing the graft.
The small incisions also lower the risk of complications like stiffness and scarring. Combined with modern graft fixation methods and well-researched rehabilitation protocols, arthroscopic ACL reconstruction has become one of the most successful and commonly performed orthopedic procedures in the world, with hundreds of thousands done annually.