When you are considering ACL Surgery, choosing which ACL replacement graft to use is not always an easy decision.
This will be the second post in our “Straightforward Diagnosis, 5 Professional Opinion Series”. Our first post focused on our approach to an 18 year old athlete and how we determined who needed to consider ACL surgery and who didn’t.
Once the decision has been made to proceed with ACL surgery, the surgeon, and you need to determine which graft would best suit your needs. Our choices include your own tissue (autograft) or cadaveric tissue (allograft). Within the autograft category we have the choice of using your:
- Patella Tendon
- Quadriceps Tendon
- and Hamstring Tendon(s).
Choosing which graft is more appropriate for your needs is not always straightforward. Let’s see what our panel of experts says.
Which ACL graft Would You Choose to Reconstruct the ACL of an 18 year old Athlete?
S.S : My preference in young patients is to use autograft. Many recent studies, including the recent MOON studies, have demonstrated that autograft is superior to allograft, with significantly decreased risk of re-rupture, in a young athletic population. The risk of re-rupture approaches equal at about age 35. My graft of choice for this patient would be a semitendinosis autograft. Harvest of this graft has lower risk and morbidity than bone-patellar tendon graft. There is a lower risk of persistent anterior knee pain and patella fracture with hamstring graft. Most studies have shown equivalent functional results, re-rupture rates and return to sport when comparing hamstring to patellar tendon grafts.
D.G. : I am a strong proponent of using autografts for young, active patients. Generally I tend to like patellar tendon grafts, but I would be fine with either a patellar tendon autograft or hamstring autograft. I do tend to worry a little bit about hamstring grafts in females due to the possibility of worsening the quadriceps:hamstring imbalance. I try to avoid allografts in young active patients due to a higher rate of reinjury that many studies in recent years have shown.
D.O. : I would typically use HAMSTRING AUTOGRAFT as my graft of choice. While bone-patellar tendon-bone autograft is another good choice, the disruption of the patellofemoral mechanism can increase chances of later patellofemoral pain and arthritis, down the line. I have some experience with quadriceps tendon allograft, and this would be another good choice as well.
J.B. : No Allografts for primary isolated ACL reconstruction in any active (usually all) pts under 45 yo. Too much data showing higher rates of failure for me. I find autografts are easy to harvest. Offer BPB and quadrupled HS autografts with preference for HS. My interpretation of the data is both provide very similar outcomes. BPB higher rate of anterior knee pain, kneeling pain, earlier PF OA and risk of patellar Fx. I’ve seen all of them except fractures in my patient (seen fractures in others). I see very little, if any, complications with HS and prefer that. No experience with Quad tendon.
S.M : Most of my experience is with bone patella tendon bone AUTOGRAFT. I recommend this graft for most of my patients. Other than the slight loss of sensation around the incision I have not had patients complain of significnant anterior knee pain. I believe this is due to the details of post op therapy which focuses on patella mobility, quad tendon stretching and maximizing knee extension. I do use bone patella tendon bone ALLOGRAFT for less active older patients (older than 40) especially if the patient cannot afford to be off work.
When discussing your ACL surgery with you, your surgeon should discuss the graft choices available, and which graft they feel is best to suit your needs.
Our panel is in agreement:
- Allografts (cadaver) grafts are probably a poor choice in an athletic population.
- Hamstring grafts are a good choice, but might cause weakness – if both of them are used.
- Patella tendon grafts are also a strong choice, but might raise the risk of residual pain in the front of the knee.
Which ACL graft is best for you? That’s a good question to ask your surgeon, and hopefully these experts have given you some key points to review with your experienced ACL surgeon.
The participants :
D.G.: Dr David Geier : Twitter: @DrDavidGeier ; Website
J. B.: Dr Jeff Berg: Twitter: @DrJeffBerg ; Website
D.O.: Dr Derek Ochiai: Twitter: @DrDerekOchiai ; Website
S.M.: Dr. Steve Mora: Twitter: @myorthodoc ; Website
S.S: Dr Scott Slattery: Twitter: @sportscaduceus ; Website:
My 13 year old daughter has a complete middle tear of the ACL and her growth plates are just about closed if not completely closed. Can you tell me if the hamstring graft is a good choice and if not, why? On average, how long does it typically take to make a full recovery before even considering a return to the soccer field?
Howard J. Luks, MD says
Hamstring grafts have a slightly higher failure rate. In addition… Females tend to be “quadriceps dominant” so taking the hamstrings can create a further imbalance due to hamstring weakness.
In the end… a well done patella tendon graft or hamstring graft function well… but the patella tendon graft has a higher risk of long term anterior knee pain… and the hamstring has the risk of weakness and a slightly higher failure rate. This requires a long talk with your surgeon.
Hello Dr. Howard,
I’m 18 years old and recently tore my ACL and have a complex tear on my lateral meniscus. What do you think I should do with my meniscus ; repair or reconstruct? Also would you choose a auto graft or allograft ? I know most doctors recommend hamstring autografts, but why? I had a friend (female) who got an allograft done and said it worked fine, it also helped her to get back into her sport quickly. I plan on playing physical sports for the rest of my life, or at least as long as my body allows me. I just need help making the right choice, I want a well balanced option ( Low risk of re-tearing with low pain and great mobility.)
Howard J. Luks, MD says
At your age we repair almost all tears. Especially in the setting of an ACL reconstruction. Many tears will heal so it’s worth having the tear sutured back together — or left in place after the ACL surgery to heal on its own.
Allografts at your age are not a good idea at all. They do not get you back to sports earlier … and they have between a 35-50% reported failure rate in your age group.
Hi, I am a 34 year old female, very active rock climber, and have just recently torn my ACL, but all my other ligaments are intact. Do some people choose to not have surgery and is that ever recommended? I know with the active lifestyle I live, surgery is recommended due to the risk of tearing the others and not being able to do the physical activities that you once did. But I also just heard a story of a friend that lived a very active lifestyle and didn’t even know she had a torn ACL. If you have all the other ligaments, do you ever recommend not having surgery?
I am also debating between the Patella Tendon and Hamstring. My doctor recommended the hamstring and I’m leaning in that direction, but I hadn’t heard about the imbalance in females between the quadriceps and hamstring. For a 34 year old female, what are your thoughts on which one to get?
Howard J. Luks, MD says
Hi Leia …
The issue with not reconstructing your knee is that you may find out that your knee is unstable at a very dangerous time. We can watch and wait on many athletes to see if their knee is stable or unstable. I’m not saying that you should definitely have surgery or not… I’m saying that your chosen activities and desire to continue to do them should enter into the decision making. If hamstring weakness will affect your ability to climb then it might not be a great graft choice.