Types of ACL Grafts and What to Expect
When it comes to ACL reconstruction, surgeons have several graft options. Each comes from a different part of the body (or occasionally from a donor) and has unique strengths and considerations. Understanding these differences can help patients know what to expect in terms of recovery, knee stability, and long-term outcomes.
1. Bone–Patellar Tendon–Bone (BPTB) Autograft
The BPTB graft is harvested from the central third of the patient’s patellar tendon, along with small pieces of bone from the patella and tibia. This bone-to-bone connection is extremely strong and heals quickly, making it a favorite for athletes in high-demand sports that require cutting and pivoting.
Pros:
Strong initial fixation due to bone-to-bone healing
Lower re-tear rates, especially in young athletes
Long history of excellent outcomes
Cons:
Higher rates of anterior knee pain and discomfort when kneeling
Small risk of patella fracture or tendon rupture
Who it’s best for: High-demand athletes, especially those in sports like soccer, basketball, or skiing.
Outcomes: Excellent long-term stability and one of the highest return-to-sport rates among all grafts.
2. Hamstring Tendon Autograft
The hamstring graft usually uses the semitendinosus tendon, sometimes with the gracilis tendon, woven into a strong, multi-strand replacement ligament. Because it spares the patellar tendon, it typically causes less anterior knee pain.
Pros:
Less anterior knee pain than BPTB
Smaller incision and less surgical trauma
Preserves the patellar tendon for potential future surgeries
Cons:
Tendon-to-bone healing is slower than bone-to-bone
Slight risk of hamstring weakness, especially in deep knee flexion
Slightly higher re-tear rates in young athletes
Who it’s best for: General population or moderate-demand athletes seeking a balance between strength and comfort.
Outcomes: Very good knee stability; long-term results are comparable to BPTB in most patients, though re-tear risk is slightly higher in younger, highly active individuals.
3. Quadriceps Tendon Autograft
The quadriceps tendon graft is taken from the central portion of the quadriceps tendon, sometimes with a small bone plug. It offers a large, strong graft with less anterior knee pain than BPTB, and it’s increasingly used in both primary and revision ACL surgeries.
Pros:
Thick, robust graft suitable for larger or revision reconstructions
Less anterior knee pain than patellar tendon grafts
Preserves hamstrings and patellar tendon
Cons:
Possible quadriceps weakness postoperatively
Less long-term data compared to BPTB or hamstring grafts
Who it’s best for: Athletes, patients undergoing revision surgery, or those who have previously had a hamstring or patellar tendon graft harvested.
Outcomes: Early studies suggest excellent stability and functional outcomes, often matching or exceeding hamstring grafts with less donor site discomfort.
4. Peroneus Longus Tendon Autograft (Emerging Option)
This newer graft option uses the tendon along the outside of the lower leg. It’s especially helpful in revision cases or when other graft sources are unavailable.
Pros:
Strong and long enough for ACL reconstruction
Preserves hamstrings and patellar tendon for future use
Minimal impact on ankle strength in most patients
Cons:
Limited long-term outcome data
Caution for athletes who rely heavily on ankle stability
Who it’s best for: Patients needing an alternative graft, particularly in revision surgeries or when hamstring/patellar tendons are unavailable.
Outcomes: Early research shows comparable knee stability and function to hamstring grafts.
5. Allografts (Donor Tissue)
Allografts use tissue from a donor, which can include patellar tendon, Achilles tendon, or hamstring. Because there’s no harvesting from the patient, surgery is quicker, and there’s no donor site pain.
Pros:
No donor site morbidity
Shorter surgery time
Cons:
Higher failure rates in young, active patients
Slower incorporation into the patient’s knee
Small risk of disease transmission (rare)
Who it’s best for: Older patients, low-demand individuals, or select revision cases.
Outcomes: Can be effective in low-demand populations but generally not recommended for younger athletes due to higher re-tear risk.
Bottom Line
Choosing the right ACL graft is a balance between knee stability, donor site impact, and the patient’s activity level. For high-demand athletes, bone–patellar tendon or quadriceps tendon grafts may offer the best long-term results. Hamstring grafts remain a reliable choice for most patients, while peroneus longus and allografts serve as alternatives when other options aren’t ideal. Discussing these choices with a knowledgeable orthopedic surgeon ensures a personalized approach that maximizes recovery and return to sport.
