ACL Graft Options
What is the best graft for an ACL?
Multiple studies show that an autograft (your own tissue) has the lowest re-rupture rate if you are under 25 years of age. In general, at age 40 years and older there is no difference between autograft and allograft (cadaveric tissue). From ages 30 to 40 years of age, the type of graft depends on the expected demand and activity level of a patient. The most commonly used autografts are hamstring, quadriceps, and patellar tendon. The most commonly used allografts are ankle, hamstring, and Achilles tendon.
How do I determine which graft to use?
Patients in general spend more time and energy than needed on choosing the type of autograft for their ACL. Multiple large studies show that the lifetime re-rupture rate is similar among the various autografts. Autograft is harvested in the first 15 to 20 minutes of the ACL procedure. Once the graft is harvested, the ACL procedure itself is the same regardless of the type of graft in that two tunnels are drilled, and the graft is fed into those tunnels.
The United States Multicenter ACL Revision Study (MARS) demonstrated that the most common reason for failure of an ACL reconstruction is not the graft but non-anatomic tunnel placement. Therefore, if your surgery is performed by a high-volume surgeon who specializes in ACL reconstruction and places tunnels in the anatomic position, then graft choice is not the most important consideration.
Watch Dr. Chen’s Video on ACL Tunnel Placement
Watch Dr. Chen’s Video on ACL Graft Passage
What are the advantages and disadvantages of the various autografts?
The main differences between each type of graft are the length and diameter of the graft, scarring from the harvest site, and residual pain or loss of function from the harvest.
Hamstring tendon has the least scarring and loss of function as each knee has 3 hamstring tendons on each side of the knee. The modern-day hamstring autograft is a two-stranded tendon composed of the gracilis and semitendinosus tendon. The two tendons are folded over to create a four-stranded hamstring graft.
Quadriceps tendon is a thick single-stranded graft that requires an additional incision above the kneecap. Patients who are concerned with cosmetics may not like the appearance of an additional scar above the kneecap.
Patellar tendon (bone-tendon-bone) is a single-stranded patellar tendon with bone blocks on either side of the tendon. The patellar tendon itself is short, and therefore this graft requires that a piece of bone be taken from both the patella and the tibia. Thus it is called a bone-tendon-bone or BTB graft. This graft requires a longer incision over the patellar tendon.
For our ACL patients who would like to read more about the advantages and disadvantages of each graft please see the specific information below:
