ACL Surgery & Graft Type Options

Graft Options Overview

1. Patellar Tendon (Bone-Patellar Tendon-Bone / BPTB)

• What it is: Middle third of patellar tendon with bone blocks from patella and tibia
• Pros: "Gold standard" for many surgeons; strong graft; bone-to-bone healing; excellent long-term outcomes; preferred for high-level athletes
• Cons: Anterior knee pain (10-30% of patients); kneeling discomfort; potential patellar tendinitis; possible patella fracture (rare)
• Best for: High-level athletes in cutting/pivoting sports; patients prioritizing lowest reinjury risk

2. Hamstring Tendon (Semitendinosus/Gracilis)

• What it is: Two of the hamstring tendons folded to create 4-strand graft
• Pros: Smaller incisions; less anterior knee pain; better cosmesis; lower risk of kneeling pain
• Cons: Soft tissue-to-bone healing (slower); potential hamstring weakness; slightly higher reinjury rate in some studies; tunnel widening
• Best for: Patients concerned about anterior knee pain; those who kneel frequently; recreational athletes

3. Quadriceps Tendon

• What it is: Portion of quadriceps tendon, usually with bone block from patella
• Pros: Large, strong graft; good outcomes; less anterior knee pain than patellar; becoming more popular
• Cons: Larger incision; potential quad weakness; less long-term data than other options
• Best for: Revision surgeries; larger patients; patients who want strong graft without patellar tendon harvest

4. Allograft (Donor Tissue)

• What it is: Tissue from deceased donor (various types available)
• Pros: No harvest site morbidity; no donor site pain; faster surgery; can be good option for multi-ligament injuries
• Cons: Higher reinjury rate (especially in young, active patients); slower graft incorporation; disease transmission risk (very low but not zero); cost
• Best for: Older patients (>40); lower activity demands; revision surgeries; multi-ligament injuries

Which Graft is "Best"?

There is no universally "best" graft. The right choice depends on:

• Your age and activity level
• Sport and position
• Return to sport goals
• Personal priorities (e.g., avoiding anterior knee pain vs. minimizing reinjury risk)
• Surgeon experience and recommendation
• Associated injuries
• Whether it's primary surgery or revision

Most important factor: Choose a surgeon experienced with your selected graft type. An expert surgeon using their preferred graft will get better results than a less experienced surgeon using a theoretically "superior" graft.

The Surgical Procedure

Modern ACL reconstruction is typically arthroscopic (minimally invasive):

• Duration: 60-90 minutes typically
• Anesthesia: General or spinal
• Incisions: 2-4 small arthroscopic portals plus graft harvest incision
• Process: Torn ACL removed, tunnels drilled in femur and tibia, graft placed and secured with screws/buttons
• Concurrent procedures: Meniscus repair/removal if needed
• Outpatient: Most patients go home same day