ACL Graft Choices
What are the options for my ACL graft and what is best for me?
The two primary categories of grafts used in ACL reconstruction are autograft, which is tissue taken from the same knee of the patient, and allograft, which is tissue taken from a cadaver donor. It has been widely recognized that autograft, has better long term outcomes in young patients and lower rates of graft failure compared with allograft(1). However, in some older athletes with limited demands, allograft can be a very easy option that may avoid surgical incisions for graft harvest.
The three main choices for autografts are patellar tendon, quadriceps tendon, and hamstrings tendon, all taken or “harvested” from the knee that is having surgery. There are pros and cons of each of these choices. Dr. Obermeyer is very versed and comfortable with each of these options. While patient preference plays a large role, Dr. Obermeyer will walk you through your decision, make recommendations, and help you select the graft that is most appropriate in your specific case.
Quadriceps tendon autograft
The graft that has achieved the most attention recently has been the quadriceps tendon, which is taken from an inch-or-so wide incision above your kneecap. This soft tissue graft does not require removing any bone and therefore is somewhat less invasive, does not come with concerns with kneeling or kneecap pain long term, and has mechanical properties similar to those of the intact ACL(2). Compared with the patellar tendon (below), the quadriceps tendon has 20% more collagen per unit area and can sustain higher loads to failure. The additional benefit of the quadriceps tendon graft is that the size can easily be customized to fit your specific anatomy, unlike other soft tissue grafts such as the hamstrings that are predetermined.
Quadriceps tendon grafts have been shown to have slight improved laxity measures and re-rupture rates when compared with hamstrings tendon grafts(3). In comparison with patellar tendon grafts, quadriceps tendon grafts may have slightly higher re-rupture rates but very similar long-term outcomes in comparison with patellar tendon grafts, without the harvest site pain and invasiveness(4).
Patellar tendon autograft
Patellar tendon autograft, also known as “BTB” (bone-tendon-bone), has been and still is considered the gold standard graft choice in ACL reconstruction(5). The reasons for this include the favorable mechanical properties, low rates of re-rupture and need for revision surgery, and bone-to-bone healing of the ends of the graft into the patient’s anatomy. Downsides of this graft choice include the larger incision in the front of the knee to harvest the graft, harvest pain at the kneecap, and possibly difficulty with kneeling after the procedure(4). Despite these drawbacks, patellar tendon grafts have the strongest initial fixation, function very well for the highest level athletes, and remain the graft of choice in professional and college athletes.
Hamstring tendon autograft
Hamstring graft is an excellent choice for patients desiring a soft tissue graft with minimal invasiveness/harvest site morbidity. The hamstring tendons (specifically the semitendinosus and gracilis) are taken from a small inch-long incision in the front of the knee, where an incision is required for ACL reconstruction anyway. The tendons are then routed within the knee joint and suspended in a fixed position to restore the ACL. Hamstrings grafts remain a popular option because of the overall comparatively easy postoperative recovery, lack of concerns with kneeling pain, and very strong function and mechanical properties of the graft.
In very young or high-risk contact athletes, especially those athletes with hyperlaxity (looseness of the joints), hamstrings grafts have a slightly higher rate of graft re-rupture. In this population other graft alternatives or adding an additional stabilizing procedure to the ACL reconstruction may be indicated to help prevent reinjury(6).
Allograft is tissue taken from a donor that is processed to clean and prepare prior to freezing. While disease transmission is a risk, it is extremely rare, with an incidence of less than 1 in one million uses. Use of allograft has the easiest surgical recovery but comes at a cost of inferior graft function and highest re-rupture rates. Due to these limitations, it is generally only reserved for older, less active patients that will not place high demands on the knee and the ACL graft(7).
How can Dr. Obermeyer help me with this decision?
Having a seasoned ACL reconstruction surgeon is important as the surgeon needs to consider your unique needs, lifestyle, and activity status. Dr. Obermeyer’s years of experience treating these injuries with many successful outcomes makes him well positioned to guide you through the decision.
Schedule an orthopedic appointment
If you have suffered an ACL tear and considering ACL reconstructive surgery, schedule a consultation with knee surgeon Dr. Thomas Obermeyer. Dr. Obermeyer specializes in ACL injuries and ACL reconstructive surgery. Dr. Obermeyer has orthopedic offices in Schaumburg, Bartlett, and Elk Grove Village, Illinois. Dr. Obermeyer regularly sees patients from throughout Illinois including Hoffman Estates, Palatine, Elgin, Streamwood, Arlington Heights, and Roselle communities.
- Kaeding CC, Aros B, Pedroza A, Pifel E, Amendola A, Andrish JT, Dunn WR, Marx RG, McCarty EC, Parker RD, Wright RW, Spindler KP. Allograft Versus Autograft Anterior Cruciate Ligament Reconstruction: Predictors of Failure From a MOON Prospective Longitudinal Cohort. Sports Health. 2011 Jan;3(1):73-81. doi: 10.1177/1941738110386185. PMID: 23015994; PMCID: PMC3445196.
- Xerogeanes JW. Quadriceps Tendon Graft for Anterior Cruciate Ligament Reconstruction: THE GRAFT OF THE FUTURE! Arthroscopy. 2019 Mar;35(3):696-697. doi: 10.1016/j.arthro.2019.01.011. PMID: 30827423.
- Nyland J, Collis P, Huffstutler A, Sachdeva S, Spears JR, Greene J, Caborn DNM. Quadriceps tendon autograft ACL reconstruction has less pivot shift laxity and lower failure rates than hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc. 2020 Feb;28(2):509-518. doi: 10.1007/s00167-019-05720-y. Epub 2019 Sep 19. PMID: 31538227.
- Dai W, Leng X, Wang J, Cheng J, Hu X, Ao Y. Quadriceps Tendon Autograft Versus Bone-Patellar Tendon-Bone and Hamstring Tendon Autografts for Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med. 2022 Oct;50(12):3425-3439. doi: 10.1177/03635465211030259. Epub 2021 Sep 8. PMID: 34494906.
- Hospodar SJ, Miller MD. Controversies in ACL reconstruction: bone-patellar tendon-bone anterior cruciate ligament reconstruction remains the gold standard. Sports Med Arthrosc Rev. 2009 Dec;17(4):242-6. doi: 10.1097/JSA.0b013e3181c14841. PMID: 19910782.
- Firth AD, Bryant DM, Litchfield R, McCormack RG, Heard M, MacDonald PB, Spalding T, Verdonk PCM, Peterson D, Bardana D, Rezansoff A; STABILITY Study Group; Getgood AMJ, et al. Predictors of Graft Failure in Young Active Patients Undergoing Hamstring Autograft Anterior Cruciate Ligament Reconstruction With or Without a Lateral Extra-articular Tenodesis: The Stability Experience. Am J Sports Med. 2022 Feb;50(2):384-395. doi: 10.1177/03635465211061150. Epub 2022 Jan 20. PMID: 35050817; PMCID: PMC8829733.
- Brophy RH, Lowry KJ. American Academy of Orthopaedic Surgeons Clinical Practice Guideline Summary: Management of Anterior Cruciate Ligament Injuries. J Am Acad Orthop Surg. 2023 Jun 1;31(11):531-537. doi: 10.5435/JAAOS-D-22-01020. Epub 2023 Jan 18. PMID: 36727995; PMCID: PMC10168113.
At a Glance
Dr. Thomas Obermeyer
- 15+ years of training and experience treating complex shoulder and sports medicine conditions
- Expert subspecialized and board-certified orthopedic care
- Award-winning outstanding patient satisfaction scores
- Learn more