6 key ACL graft options leading into surgery - which type is best for you? - ACL Injury Recovery (2023)

If the decision is made to have ACL surgery, then there are some ACL graft options you might want to avoid!

6 key ACL graft options leading into surgery - which type is best for you? - ACL Injury Recovery (1)

  • The majority of ACL tears are from non-contact injuries. You don’t have to be on a sports field to hear the dreaded pop.
  • For those who choose to have an ACL reconstruction, where to harvest the new graft is an important question. In this article, we discuss 6 key ACL graft options you should understand before undergoing an ACL operation.

Can the new ACL graft fail?

  • The research suggests that ACL graft types taken from your own body tissue have historically had the lowest retear rates amongst athletes returning to sport.
  • But even if you do everything right the research indicates that about 10 to 15% of ACL reconstructions will fail.
  • Whilst other graft options such as LARS and allografts have been less successful than grafts taken from your own body. For this reason, many surgeons will recommend avoiding these options.
  • ACL graft choice preferences will vary from surgeon to surgeon and thetype of ACL graft chosen for an ACL operation will often come down to your surgeon’s preference.
  • The choice of surgeon can also impact the success of ACL surgery. You should choose a surgeon who is highly experienced performing multiple ACL reconstructions every single month and has a good reputation in the community.

Where do you start with choosing the right ACL graft?

6 key ACL graft options leading into surgery - which type is best for you? - ACL Injury Recovery (2)

  • So which ACL graft type should a person choose if they elect to undergo ACL reconstruction surgery?
  • Firstly, it is important to note that one of the first things to consider is the decision of whether or not to have ACL surgery in the first place. ACL reconstruction surgery is an elective procedure.
  • Electing to have ACL surgery should be discussed carefully with your surgeon and trusted practitioner.
  • There are also some other important decisions that you need to make about your surgery.
  • This includes choosing a trusted and highly credentialled surgeon to perform the reconstruction surgery, the ACL graft type and the most appropriate timing for the surgery.
  • In terms of ACL graft options, one of the key points to note is that surgeons often prefer to take tissue from your own body to harvest the ACL graft.
  • This includes the patella, hamstring and quadriceps tendon.
  • Yet the surgeon’s preference will often be linked to what they have seen to be successful in their own past experiences.
  • As a result, one surgeon’s preference for a particular type of ACL graft can be different from another surgeon’s. If you disagree with the surgeon’s preference then do not hesitate to get a second opinion.

Where do ACL grafts get harvested from?

Many surgeons prefer to take tissue from your body to create the new ACL graft as the success rates have historically been the highest. This includes the:

(Video) My ACL Surgery Recovery Journey As a Physiotherapist

    • Hamstring Tendon Autograft: Surgeons use a hamstring tendon from the back of the patient’s thigh
    • Patellar Tendon Autograft: In this procedure, surgeons use a portion of the patient’s tendon that connects the kneecap and shin, and
    • Quadriceps Tendon Autograft: Taking a portion of the quadriceps tendon is another option for surgeons to create grafts.
  • As discussed below, each of these 3 autograft options has there pros and cons.
  • 3 further graft options that you should be aware of include donor grafts, LARS and bridge enhanced ACL repair (BEAR).
  • BEAR is a more recent approach to ACL repair which requires more research to evaluate the effectiveness of the procedure.

How many ACL tears are there in a year and what are the success rates?

  • In terms of statistics, according to the Boston Children’s Hospital there are approximately 400,000 Anterior Cruciate Ligament injuries every year in the United States.
  • The statistics indicate that the re-tear rate for ACL reconstructions can be as high as 20% for teens and up to 80% of patients will develop arthritis 15 to 20 years after surgery.

6 Key ACL Graft Options

  • Once the decision is made to have ACL reconstruction surgery traditionally most people opt for either a patella or hamstring graft to replace the severed ACL graft.
  • In more recent times the quadriceps graft has started to gain in popularity as an alternative option.

ACL graft option Number 1 – Patella tendon

  • In the patella tendon graft procedure, surgeons use a portion of the patient’s tendon that connects the kneecap and shin.
  • Many surgeons prefer to use a patella tendon graft as it closely resembles the torn ACL.
  • A patella tendon graft is approximately the same length as the ACL and the bone ends of the graft can be placed into the bone where the ACL attaches.
  • The disadvantages of using a patella tendon graft are that there is potential for risk of experiencing pain at the front of the knee. In particular where the patella tendon graft was taken.

ACL graft option Number 2 – Hamstring tendon

  • Surgeons use a hamstring tendon from the back of the patient’s thigh.
  • The hamstring tendon is where two of the tendons of the hamstring muscle are effectively removed and bundled together to create a new ACL graft.
  • One of the key advantages of using a hamstring tendon graft is it avoids the common problem associated with using a patella tendon graft where pain is known to occur at the front of the knee.
  • This is not a problem with hamstring tendon grafts as the incision to obtain the graft is smaller and overall the pain is thought to be less.
  • One of the key disadvantages with hamstring tendon grafts is it takes a longer period of time for the graft to become rigid and therefore people often need longer to be protected whilst the graft heals into place.
  • Further, hamstring grafts have in some studies shown to result in less strength of the hamstrings after surgery.

Patella tendon v hamstring tendon autograft

  • Whilst patella tendon revision rates are thought to be lower than hamstring tendon grafts, it is clear that both graft options have low revision rates and are excellent choices for ACL grafts.
  • In other words, both the patella and hamstring tendon grafts are well regarded for their use in ACL reconstruction surgery

ACL Graft Option Number 3 – Quadriceps tendon

  • The quadriceps tendon tissue has become more popular in recent times and is now considered to be a genuine alternative to the patella and hamstring grafts.
  • There are a number of reasons why you might opt for a quadriceps tendon graft including:
    • You are concerned about developing post surgery patella tendonitis.
    • You are involved in kicking sports and therefore do not want a hamstring tendon graft as you are concerned about weakening your hamstrings.

ACL Graft Option Number 4 – Allograft Donor Tissue

  • An Allograft is tissue (also referred to as Cadaver tissue) such as a ligament, bone or tendon that is surgically implanted from one person to another.
  • Whereas an autograft takes tissue from one part of your own body for transplant to another part of your body.
  • Allografts can be used in a number of different medical procedures such as shoulder or ankle repairs, plus also used as an ACL graft option for reconstructions.
  • The allograft tissue can come from death where a person has consented (or consent is provided through family) to donate his or her tissue to another individual to enhance their quality of life.
  • According to some sources, there are approximately 1 million allograft medical procedures in the United States every year and have been used for approximately 150 years.
  • Some studies have shown that an allograft may not be as strong as a patient’s own tissue leading to an increased risk of re-tear.
  • For many patients however the strength of an allograft may be sufficient to meet their demands.
  • Patients may elect to have an allograft from a donor because they are told by some physicians that there is less pain and they can return to sport sooner.
  • However, you need to be cautious. When it comes to an ACL reconstruction the research suggests that donor tissue has a significantly higher failure rate when compared to tissue taken from your body.
  • In some cases where a donor graft has been used to create an ACL, the body has essentially rejected the tissue and revision surgery has been required.

ACL Graft Option Number 5 – Ligament Augmentation and Reconstruction System (LARS)

  • LARS which stands for Ligament Augmentation and Reconstruction System is effectively the use of artificial polyester material to replace an injured ACL graft.
  • When it comes to ACL reconstructions for professional sports athletes, one of the most hotly debated topics in media circles is whether or not an athlete is using LARS or the traditional patella tendon or hamstring tendon graft options.
  • The key advantages of using LARS are the significantly reduced ACL recovery times which allow athletes to return to sport in a quicker time frame.
  • However, there are some concerns around the failure rates of LARS which has promoted many surgeons to continue using the traditional autograft options rather than LARS for their patients.

ACL Graft Option Number 6 – Bridge Enhanced ACL Repair

  • Bridge Enhanced ACL Repair (BEAR) is a relatively new technique which uses stitches and injection of the patients own blood to stimulate the healing of a torn ACL.
  • BEAR stimulates a torn ACL to heal itself and eliminates the need for a tendon graft.
  • It is hoped that this method which aims to repair the existing torn ACL rather than replace the graft, will reduce the time it takes to recover from ACL surgery.
  • Plus possibly reduce the long term risk of arthritis in the injured knee.
  • However, currently, BEAR is still a relatively new procedure and has been trialed on a limited number of patients and animal models.
  • The goal of current and future studies is to determine whether or not this new technique is as reliable as a reconstruction for patients.
  • Plus to determine the levels of revision rates compared to the traditional ACL autograft option.

Do you need to repair your torn ACL?

  • Not everyone who injures their ACL needs to have ACL reconstruction surgery to replace the torn graft.
  • There is normally no urgency to make a decision to have an ACL operation unless significant instability is evident.
  • Not having ACL surgery is a very realistic option that people do choose if the circumstances are right for them.
  • There are instances where your surgeon will recommend not having an ACL reconstruction.
  • For example, for older and non-active people, surgeons may choose not to repair the ACL at all, but rather recommend a rehabilitation program that includes strengthening and mobility exercises.
  • Click here to find out more about whether or not you will require ACL reconstruction surgery.

How is the new ACL graft inserted into your knee?

  • An ACL reconstruction is performed by an orthopedic surgeon and takes one to two hours to complete.
  • The procedure is typically performed through arthroscopy which includes preparing the new graft, removing the torn ligament, and attaching the new tendon to bone for better fixation and healing.
  • The benefits of arthroscopic procedures include ease of viewing and manipulating the knee, smaller incisions, ability to complete surgery at the time of diagnosis, and fewer risks compared to open procedures.
  • ACL reconstructions aim to produce a result that is close to the original structure as possible.
  • Better techniques now mean patients spend less time in hospital however once the nerve block wears off you will still need pain killer medication.

(Video) Which Graft To Chose For ACL Surgery


  • When it comes to ACL surgery, the choice of ACL graft type is an important consideration because statistically the graft type can impact failure rates and your the duration of your ACL recovery timeline.
  • Choosing the right ACL graft is even more important if you intend to return to playing a high level of sport which requires a lot of pivoting and twisting movements of the knee.
  • The selection of ACL graft type often comes down to your surgeon’s preference which can vary from surgeon to surgeon. The preferred graft type for surgeon’s continue to evolve over time.
  • Many surgeons prefer to take tissue from your own body to create the new ACL graft as the research indicates that these options have lower failure rates. This includes the patella, hamstring and quadriceps tendon.
  • In terms of stability and functional outcomes each of these 3 options will work if performed by a good surgeon. Yet each option has its own pros and cons which you should discuss with your surgeon and physical therapist.
  • Allografts or donor grafts whilst can also be popular amongst some surgeons because they save surgeons time but are not ideal because they have comparatively higher failure rates, especially in young people.
  • Another option is the possibility of using stem cells to grow your own ACL. This is a relatively new procedure which eliminates the need for a tendon graft. However, using stem cells requires more research to determine if it works and is durable.
  • It is advisable to talk to multiple surgeons and therapists to understand what is the right ACL graft option for you.
  • Importantly, you also need to find a good surgeon who performs many ACL reconstructions each month. Speak to your local physical therapist or doctor for assistance & recommendations. It can never hurt to get more than one opinion.
  • If the decision to have ACL surgery is made, then an intensive and robust rehabilitation including adherence to a specific exercise program is required.

Good Luck With Your ACL Injury Rehabilitation!

Click the link below for a copy of your Free ACL recovery checklist or go to:


(Video) ACL Injury & Reconstruction - Everything you need to know

ACL Graft Options Video

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What is the best ACL graft options? ›

The patellar tendon graft (PTG) has always been the gold standard for anterior cruciate ligament (ACL) reconstruction. Yet, most orthopedic surgeons prefer hamstring grafts for younger athletes and cadaver grafts for older patients.

Which is better allograft or autograft ACL? ›

Conclusion. In ACL reconstruction, clinical results with autografts are as good as or slightly better than with allografts. Allografts cost more, indicating that autografts are more cost-effective and should usually be first choice.

Which ACL graft heals the fastest? ›

Allografts typically have the quickest recovery due to the fact that there is no additional disruption to your own tissue. Although, they also have a higher rate of rupture (re-injury) in general when compared to autografts.

What are 3 graft options for replacing a torn ACL? ›

The three options for torn ACL reconstruction that Dr. Bennett describes in the video are the hamstring autograft, the tibialis allograft, and the patellar tendon graft.

What is the most common graft used for ACL reconstruction? ›

Hamstring tendon grafts are one of the most commonly used grafts for ACL reconstruction. The semitendinosus tendon with or without gracilis tendon is harvested, from ipsilateral leg. They are used as quadruple stranded grafts and are comparable to native ACL.

Which technique is best for ACL surgery? ›

Patellar tendon graft reconstruction of the ACL (Kenneth Jones or KJ technique) This procedure necessitates the surgeon to take a piece of the patellar tendon that is located below the kneecap (aka. patella) of the patient and use it in place of the torn ligament.

What is the most common way to repair an ACL? ›

Today, most surgeons depend on knee arthroscopy, which is considered the best way to repair an ACL tear.

Which ACL graft is best for athletes? ›

Patellar Tendon

It is the graft with the longest track record and is consider by many to be the “gold-standard” for ACL reconstruction. In most circumstances this is the graft recommended for professional athletes and in any young active individual.

What is the most painful ACL graft? ›

1, 2 Still, the most commonly used autografts for ACL reconstruction are the bone-patellar tendon-bone (BPTB) and hamstring tendons (HT). There is some evidence to suggest that BPTB autografts produce more pain than HT autografts both in the immediate postoperative period as well as in the long term.

What type of bone graft is best? ›

Allograft is the most commonly used bone graft material. Allograft means the bone graft material comes from another human. It is a donor tissue that is very safe to use, and the body receives it very well.

Is quadriceps tendon autograft a better choice than hamstring autograft for anterior cruciate ligament reconstruction? ›

There was no difference between groups in terms of isokinetic strength. Conclusion: The use of a QT graft in ACL reconstruction leads to equal or better functional outcomes than does the use of an HT graft, without affecting morbidity.

Is hamstring graft good for ACL? ›

Although there are a variety of autograft and allograft options available for ACL reconstruction, advantages of hamstring tendon autografts include decreased postoperative knee pain and an overall easier surgical recovery compared with bone patellar tendon bone autograft.

When is ACL graft weakest? ›

ACL grafts are weakest 5 to 12 weeks after surgery. You may feel stronger, but your knee is months from full recovery.

Is a quad graft good for ACL surgery? ›

Recently, the quadriceps tendon has gained popularity for use as a graft source for ACL reconstruction. The all soft tissue quadriceps graft offers many advantages over other autograft choices. Histologically it has 20% more collagen fibrils per cross-sectional area than the patellar tendon (PT).

Which ACL graft is an allograft? ›

Usual allograft sources for anterior cruciate ligament (ACL) reconstruction are patellar ligament, Achilles tendon, tibialis anterior, and posterior. The advantages of the use of allograft include reduced donor-site morbidity, shorter operative time, smaller incisions, and no size restrictions.

What is allograft for ACL? ›

Anterior Cruciate Ligament (ACL) Reconstruction with Allograft reconstruction is a surgical tissue graft replacement of the anterior cruciate ligament, located in the knee, to restore its function after Anterior Cruciate Ligament injury.

Which graft is the most commonly used? ›

Autografts. Autografts are the most frequently used bone grafts in spinal surgery. They are considered the “gold standard” since they provide the most predictable results.

What is the most common type of graft? ›

Grafting techniques

Skin grafting is the most common type of grafting, although many other tissues can be grafted as well: skin, bone, nerves, tendons, neurons, blood vessels, fat, and cornea are some of the most routinely transplanted tissues today.

What is the most common graft? ›

By far, autograft tendons are the most commonly used. Autografts in ACL reconstruction are tendons harvested from the patient's own body at the beginning of the procedure and prepared as a tissue graft that can be inserted into the knee during the same procedure in an attempt to restore the normal anatomy of the ACL.

Which type of ACL needs surgery? ›

Types of ACL injuries

While complete ACL tears almost always require surgery, partial ACL tears may be treated effectively with nonsurgical methods. ACL tears are graded by severity and are called sprains (a sprain is a stretch or tear in a ligament).

Is quadriceps tendon a better graft choice than patellar tendon? ›

The advantages of the quadriceps tendon graft include, the graft is larger and stronger than the patellar tendon, morbidity of the harvest donor site is less than that of patellar tendon graft, no quadriceps inhibition is seen after the quadriceps harvest, and with aggressive rehabilitation, there is shorter recovery ...

What type of surgery is done in ACL? ›

During ACL reconstruction, the torn ligament is removed and replaced with a band of tissue that usually connects muscle to bone (tendon). The graft tendon is taken from another part of your knee or from a deceased donor.

What are two forms of treatment for an ACL tear? ›

There are two treatment options for ACL injury: Nonsurgical treatment such as a brace to protect from instability and physical therapy to strengthen the surrounding ligaments to provide greater stability. Surgical reconstruction of the ACL to restore the internal structures of the knee to enable maximal stability.

When is ACL graft strongest? ›

Early Graft Healing Phase (0 - 4 Weeks After Surgery)

Therefore, right after surgery, the graft is typically stronger than the original ACL.

Does ACL reconstruction lead to knee replacement? ›

People with a history of an anterior cruciate ligament (ACL) reconstruction are 5 times more likely to receive a total knee replacement than the general population.

What ACL graft do NFL players use? ›

Conclusions: BPTB is the most frequently used graft for ACL reconstruction by NFL and NCAA Division I team physicians in their elite-level running backs. Nearly all surgeons always use a single- bundle technique, and most do not recommend a brace on return to sport in running backs.

How often do ACL grafts fail? ›

Approximately 200,000 anterior cruciate ligament (ACL) ruptures occur in the United States annually. Primary ACL reconstruction is recognized as a successful procedure, but failure has been shown to occur in approximately 10% of patients.

How long do ACL grafts last? ›

Rebuilt to last

Not only is the procedure effective, but repaired tendons perform like new. Reconstruction patients even 20 years later revealed excellent performance, with over 85% still active.

Are patella allograft good for ACL surgery? ›

The patellar tendon graft has proven to be one of the strongest and most reliable for ACL reconstruction. Patients who have this operation generally get back to their usual activities and sports.

Which type of graft is most successful? ›

The common variation is a whip and tongue graft, which is considered the most difficult to master but has the highest rate of success as it offers the most cambium contact between the scion and the stock. It is the most common graft used in preparing commercial fruit trees.

What hurts more bone graft or implant? ›

Patients who are having supplemental procedures such as bone grafts and sinus lifts may also experience slightly more discomfort than say a patient who is undergoing a simple dental implant.

What are the four types of graft? ›

Several different methods are commonly used for grafting plants. These include cleft grafting, inlay grafting, four-flap grafting, and whip grafting.

Why do synthetic ACL grafts fail? ›

Intrinsic failure of the graft can occur from graft impingement or trauma. Recent reports have noted a 2% traumatic rupture rate of autogenous ACL reconstruction and a 15% rupture rate for allograft. In the case of allografts, a low level of immunologic reaction can weaken the graft and cause early failure as well.

Is hamstring graft strong? ›

Since it has four tendon strands, the graft is very strong, up to two or three times the native ACL. Hamstring grafts have been associated with better extension, lower incidence of post-surgical arthritis and better extension strength.

How long does a hamstring graft for an ACL take to recover? ›

This usually takes four to six months.

Which of the following graft types has the highest failure rate after ACL reconstruction surgery? ›

Comparison of graft types showed that hamstring tendon autografts had a yearly graft failure rate of 1.70%, whereas the bone–patellar tendon–bone autograft group had 1.16%, the quadriceps tendon autograft group 0.72%, and the allografts 1.76%.

When is ACL weakest after reconstruction? ›

The graft complex is actually at its weakest at around the 6 week post operative mark. Kinematic research has shown that open chain exercises cause significantly more anterior tibial displacement and hence more strain on the graft than closed chain exercises.

What ACL graft do NBA players use? ›

14,24 As our present investigation found that 87% of NBA team physicians were using autograft in ACL reconstructions in high-level athletes, these physicians likely agree with the recent literature showing autograft associated with the lowest re-rupture rate and the highest chance of return to sport.

How long does allograft ACL last? ›

Survival of the Anterior Cruciate Ligament Graft and the Contralateral ACL at a Minimum of 15 Years.

What is the best way to repair an ACL? ›

Complete ACL tears are usually treated by sports medicine physicians and orthopedic surgeons with an ACL reconstruction surgery, in which the torn ligament is replaced with a tissue graft to mimic the natural ACL.

Can your body reject an ACL graft? ›

Although only 10% of grafts fail, this is still a large number of cases. There can be many reasons for an ACL reconstruction failure. The most common reason for an ACL graft to fail is due to technical issues with the original surgery.

When is ACL reconstruction the weakest? ›

The graft is at its weakest at 3 to 6 months – just when the patient is beginning to regain confidence. It is therefore essential that return to proper sport is delayed until 9 months post-op.


1. How can I avoid injuring my ACL graft?
(Dr. David Geier)
2. Should You Rehab Your Torn Anterior Cruciate Ligament (ACL) Injury Without Surgery?
(E3 Rehab)
3. Anterior Cruciate Ligament reconstruction (ACL Reconstruction): What You Need to Know
(Medical Centric)
4. ACL Injuries: Recent Advances and Best Practices
(Northwell Health)
5. ACL Reconstruction Graft Choices
(Howard Luks)
6. Pitfalls of ACL Reconstruction in Professional Athletes
(RWJBarnabas Health)
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