Which Graft Is Best for ACL Reconstruction?

One of the most important decisions during ACL (anterior cruciate ligament) reconstruction is choosing the right graft, the tissue used to replace the torn ligament. The choice affects recovery time, knee strength, and long-term stability.

There’s no single “best” graft for everyone. The ideal option depends on your age, activity level, sport, previous injuries, and surgeon’s expertise.

The Main Types of Grafts for ACL Reconstruction

1. Hamstring Tendon Autograft

This graft uses tendons taken from your own hamstring (usually the semitendinosus, and sometimes gracilis).

Pros:

• Smaller incision and less knee pain after surgery
• Lower risk of anterior knee pain compared to patellar grafts
• Good strength and flexibility

Cons:

• Slightly longer healing time for graft to fully incorporate
• Potential for hamstring weakness early in recovery

Best suited for:

• Recreational athletes
• Patients concerned about front knee pain
• Those wanting a less invasive harvest site

2. Patellar Tendon Autograft (Bone–Patellar Tendon–Bone)

This option uses the middle third of your patellar tendon, along with small bone plugs from the kneecap and shinbone.

Pros:

• Strong fixation with bone-to-bone healing
• Excellent long-term stability for high-impact sports
• Lower risk of graft stretching over time

Cons:

• Can cause anterior knee pain or pain when kneeling
• Slight risk of patellar fracture or tendonitis

Best suited for:

• Younger, high-level athletes
• Contact or pivoting sports (football, basketball, rugby)
• Those prioritising maximum knee stability

3. Quadriceps Tendon Autograft

Taken from the front of the thigh, this graft is gaining popularity as a strong and versatile option.

Pros:

• Large, durable graft with strong fixation
• Less anterior knee pain than patellar grafts
• Can be used in revision ACL surgeries

Cons:

• Mild quadriceps weakness initially
• Slightly newer technique with less long-term data (though outcomes are excellent so far)

Best suited for:

• Larger or taller patients
• Revision surgeries
• Patients who experienced patellar tendon issues before

4. Allograft (Donor Tissue)

This uses a graft from a donor rather than the patient’s own tissue.

Pros:

• Shorter surgical time and smaller incision
• Less pain at the graft site
• Useful for multiple ligament injuries or revisions

Cons:

• Slightly higher failure rate in young, active individuals
• Longer graft incorporation time
• Small risk of disease transmission (extremely rare)

Best suited for:

• Older or less active patients
• Multi-ligament injuries
• Revision ACL reconstruction

Factors That Determine the Best Graft for You

• Age: Younger patients tend to do better with autografts (their own tissue).
• Activity level: High-impact athletes often benefit from patellar or quadriceps grafts.
• Occupation: Jobs requiring kneeling might make hamstring or quadriceps grafts more suitable.
• Previous surgeries: Prior tendon harvests or injuries can limit graft options.
• Surgeon experience: Surgeons tend to have preferred grafts based on expertise and outcomes.

Success Rates by Graft Type

Studies show that all major graft types have high success rates:

• Autografts: 90–95% success rate
• Allografts: 80–90% success rate (slightly lower in younger patients)

The difference often lies not in the graft itself, but in proper surgical technique and post-operative rehabilitation.

Conclusion

The best graft for ACL reconstruction depends on your personal goals, age, and activity level.

• Patellar tendon grafts offer excellent stability for athletes in cutting or pivoting sports.
• Hamstring grafts provide good strength with less kneeling pain.
• Quadriceps grafts are a strong, modern alternative with great outcomes.
• Allografts are suitable for older or lower-demand patients.

Discussing these options with your orthopaedic surgeon will help you choose the graft that offers the best balance of strength, comfort, and long-term success for your lifestyle.