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:
Eileen says
My 16-year-old son is scheduled for ACL repair surgery (football injury) this Friday, October 23. A close adult friend has had two ACL surgeries within the year and was given Exparel. He insists that initial recovery and rehab is much easier than with other meds. What is your opinion on Exparel?
Howard J. Luks, MD says
Exparel is fine … it is very expensive and not available in many surgery centers. Besides, the exparel only works for a day or two… so it will not make a big difference either way. It’s a painful procedure anyway you slice it :-(
Steve says
I am a 31 year old male. I tore my right ACL and medial meniscus playing soccer on June 7th. I had an MRI confirm this diagnosis. I am scheduled for surgery with patella tendon graft on November 19th. Since my injury I have become able to return to my normal life with the exception of returning to sports. I am able to ride a bicycle and squat with added weight without any pain. If I did not know my ACL and meniscus were torn I would attempt to return to sports. In other words my knee feels completely stable. Is it common for an ACL absent knee to feel this stable? Is there any way my knee could be stable enough to return to competitive sports without an ACL?
Howard J. Luks, MD says
this is a pretty common story. Not everyone who has an ACL tear needs ACL surgery.
dev says
Hi Doctors,
I had an acl reconstruction and meniscus repair about 3 or 4 years ago. The doctor used my hamstring. Ever since the surgery i never really recovered and have not been able to play any sports. when i try my knee just buckles and i fall. i got another mri scan done and it shows that there is a tear again but the ligament is not all gone. the doctor insists that i can get better with only physio and that i don’t need another surgery. What do you think?
Howard J. Luks, MD says
Unfortunately the ligaments do not strengthen or tighten over time.
Rosann says
I would like some feedback as well. My 14 yr old daughter tore both of her meniscus and her ACL from falling from a cheer stunt. Her surgeon did not give us any choices on graphing only patellar tendon. She was also a gymnasts for 11yrs. She is very active and wants to return back to being a flyer in cheer. Her growth plates are pretty well closed in the knee. Which graphing would be the best option for her.
Howard J. Luks, MD says
The other choices include the patella tendon and quadriceps tendon grafts…. perhaps you want to speak with a second opinion ??
Ben says
What are your thoughts on allograft for patients over 35? I’m 38, in good health and fitness and had my ACL reconstructed 5 days ago using a cadaver graft. It was what my surgeon recommended based on my age, activity level, etc. I’m not in competitive sports, but I do like to attend a crossfit class a couple times per week, run 5Ks, bike, and ski a couple times per season. My work is sedentary, but I break up the day by walking at lunch.
I also had a bucket handle tear and they removed 75% of my meniscus. I realize that will affect my ability to return to any high impact sports (running) but I’m willing to modify my exercise routines as they are all recreational.
Given my age, level of fitness, and exercise routine, do you believe this was the best choice of graft?
Howard J. Luks, MD says
In certain people it is a good choice … go with it.