The art of letting go: Recognising limits in joint‐preserving ligament surgery—The enemy of good is better

As the knee surgery community continues to evolve, there is increasing pressure to innovate, sometimes ahead of the evidence base and potentially to the detriment of our patients and their outcomes. This over-enthusiasm has several drivers: the medical device industry's desire to expand revenue and market share, an arguably excessive number of conferences and meetings, and the continuous pressure on key opinion leaders to generate new topics and insights. While the vast majority of surgeons who rapidly adopt new techniques are motivated by a genuine commitment to improving patient care, others may also be influenced by professional ambition or commercial opportunity. For these reasons, high-volume key opinion leaders who consult for industry, teach on courses, and lecture at conferences must remain acutely aware that many of their peers who look to them for guidance have lower-volume or more generalist practices. These leaders carry a moral and ethical responsibility to ensure that their advice is strictly evidence-based, and to recognise that what may represent a worthwhile change in practice for a high-volume specialist could pose a potential risk when applied in a lower-volume or generalist setting. All too often, our community seeks the answer to a surgical problem; the best graft, the best technique, the best device, as if there were a single, universal solution. This notion is flawed. Most of the time, there are multiple valid solutions to a given clinical problem, and no single ‘Correct’ answer applicable to all scenarios or all surgeons. The concept of individualised patient care, often referred to as an ‘à la carte’ approach, has gained popularity in the sports orthopaedics community, with individualised graft choice for anterior cruciate ligament (ACL) reconstruction being a prime example. While high-volume surgeons may indeed achieve superior results through individualisation, this is not necessarily true for low-volume practices. In fact, it may further dilute experience and consistency. For instance, applying an à la carte graft philosophy in a practice performing around 20 ACL reconstructions (ACL-R) per year could result in fewer than 10 cases per graft type, insufficient to maintain technical proficiency. In such settings, a more standardised or ‘set-menu’ approach may be preferable, maximising procedural volume, reproducibility and team familiarity. Alternatively, healthcare systems must decide whether certain procedures should be restricted to high-volume centres/surgeons, as already implemented in countries such as Denmark, thereby concentrating experience and theoretically enhancing outcomes. It has long been suggested that surgical volume correlates with outcome in orthopaedics, but until recently, supporting evidence was limited. Rizvanovic et al. [9] analysed the Norwegian registry and found that high-volume surgeons had shorter time to surgery, reduced operative time, lower perioperative complication rates and less frequent use of nonroutine antibiotics (p < 0.001). Defining what constitutes ‘low’ and ‘high’ volume remains contentious. Tuca et al. [14] conducted a global ACL benchmarking study and used a cutoff of 25 cases per year to define very low volume. Similarly, Dadoo et al. [5] demonstrated that high-volume surgeons were more than four times more likely to perform a meniscal repair at the time of ACL-R. While there is likely a threshold below which a surgeon should consider referring such cases to a higher-volume centre, our community must recognise that there is also a range of practice that is safe and appropriate, where the surgeon is not ‘High volume’ but still provides high-quality, guideline-adherent care. In these cases, a consistent and standardised approach may offer greater safety than an individualised, à la carte strategy. ACL revision rates average around 7% [15], and are even higher in young athletes, contact sports and competitive populations. Clinical practice guidelines can assist surgeons in establishing a thorough preoperative evaluation and optimal surgical planning [13]. Surgical strategy depends on factors such as the graft previously used, tunnel position and widening, associated meniscal lesions (In particular, ramp and root tears), peripheral lesions (e.g. posterolateral corner, anterolateral corner and tibial collateral ligament lesions) and limb alignment in both coronal (varus) and sagittal (tibial slope) planes [3]. Revision ACL-R remains highly demanding, with outcomes inferior to those of primary ACL-R. Surgeons must therefore be proficient in multiple graft harvest techniques, lateral extra-articular procedures, complex meniscal repair and must appreciate the role of slope-reducing osteotomies. A surgeon performing less than 50 ACLs per year may only perform three revisions and will face challenges in maintaining ACL revision expertise. This once again raises the important and sensitive question: how strongly is surgical outcome linked to procedural volume? While volume-based certification systems are well established in other surgical specialties, such as oncologic surgery [1], surgeon volume is not the only—and perhaps not the most critical—determinant of care quality [10]. One of the key clinical questions is: When does ligament reconstruction cease to be appropriate in a degenerative joint? Caution is warranted when there is established severe compartmental osteoarthritis (OA), particularly medially. Even preexisting mild to moderate OA is not associated with inferior patient-reported outcomes (PROMs) after ACL-R [2, 4]. Patients aged 40 years and older, including those with Outerbridge grade III/IV chondral lesions or Kellgren-Lawrence grade 2 + OA, experience significant improvements in PROMs such as Knee Injury and Osteoarthritis Outcome Score (KOOS), Single Assessment Numeric Evaluation (SANE), Lysholm and International Knee Documentation Committeescores postoperatively, with no correlation between baseline OA severity and the magnitude of improvement [2, 4, 7]. However, performing ACL-R in a knee with progressive medial degeneration, even in the presence of mechanical symptoms, often fails to yield durable benefit and may simply postpone the inevitable arthroplasty. In such cases, the ligament is no longer the problem—it is merely a marker of an already failing joint. Furthermore, chronic ligament deficiency often leads to secondary meniscal and chondral damage. Once these structures are irreversibly compromised, even technically flawless ligament surgery will not restore function. Here, the limit of joint preservation is set by biological reality rather than surgical capability, especially in the older patient. This transitional zone between ligament reconstruction and arthroplasty is not a binary decision but rather a continuum of joint-preserving strategies. High tibial osteotomy, partial resurfacing techniques and unicompartmental knee arthroplasty can serve as intermediate options that bridge the gap between biological preservation and mechanical replacement. Defining this ‘Grey zone‘ quantitatively—by the degree of cartilage loss, mechanical alignment or patient-reported instability—remains one of the key challenges in modern knee surgery. Patient-specific anatomy also defines the boundaries of ligament-preserving surgery. Morphological features such as a markedly increased posterior tibial slope (> 12° on short lateral radiographs with at least 15 cm of tibia) [11] or valgus malalignment [8] create challenging environments for graft stability. Repeated graft failures in such settings are common. Similarly, combined injuries such as concurrent collateral ligament injury, complex meniscal pathology or chondral injuries predispose to ACL-R rerupture. Surgeons undertaking ACL-R should be meticulous in their preoperative assessment, and where the surgical care required sits within their scope of practice, they should proceed. Where the scope of practice sits outside their scope of practice, then they should strongly consider onward referral to a specialist centre. In patients with generalised ligamentous laxity (Beighton score > 4) or hypermobility (> 10° knee hyperextension), hamstring autografts may be suboptimal; a bone–patellar tendon-bone–bone (BPTB) graft may offer greater stability [6, 16]. Conversely, a limited preoperative range of motion increases the risk of postoperative arthrofibrosis. Full extension and flexion deficit within 10° of the contralateral joint should be achieved before ACL-R. This is achieved primarily by physiotherapy, and rarely arthrolysis [12]. If arthrolysis is required to achieve motion, the knee may already be sufficiently stable that reconstruction is unnecessary. In revision cases, these considerations become even more critical. A failed primary ACL-R in a patient with increased tibial slope and medial meniscus deficiency is unlikely to succeed with another isolated graft. Unless these structural risk factors are addressed, the surgical limit has already been reached before the second operation begins. Functional limits also exist, particularly when objective instability accounts for only part of the patient's complaints. Chronic pain, loss of confidence, or impaired performance in the absence of true mechanical instability seldom improve with reconstruction—and may worsen due to postoperative disuse, prolonged rehabilitation and unmet expectations. Patient selection and communication are therefore crucial. A technically perfect reconstruction in a low-demand, comorbid patient may achieve radiographic success but clinical disappointment. Joint-preserving ligament surgery is not a universal remedy. As we embrace innovation and refine our surgical capabilities, we must also recognise the biological, anatomical, functional, surgical and technical limits that define responsible practice. Acknowledging these boundaries is not a sign of defeat — it represents surgical maturity and patient-centred wisdom. Ultimately, success in modern ligament surgery is defined not only by what we can do, but by what we choose not to do when the joint or the patient context counsels restraint. The art of letting go, therefore, does not imply therapeutic resignation but rather clinical discernment—the wisdom to recognise when biology, mechanics, and patient context no longer justify reconstruction. By defining these thresholds, our field can evolve from anecdotal decision-making toward evidence-based stratification between joint preservation and arthroplasty. Only then can we truly claim mastery over the full spectrum of knee restoration. The authors have no funding to report. The authors declare no conflicts of interest. The authors have nothing to report.