What is the best graft for an ACL Reconstruction?

For the majority of young and/or high-level athletes we tend to use their own tissue known as autograft, as opposed to allograft (tissue from a donor). Patients always want to know which graft is the best, but it is important to understand that there is NO PERFECT GRAFT to replace your ACL. Each graft has advantages and disadvantages. All three autografts have shown success in intermediate and long-term studies with relatively low failure rates.

Patellar Tendon autograft

Patellar Tendon autograft has the best graft incorporation (due to bone on both ends of the graft) and has the strongest fixation method using screws to fix it to your bone. Disadvantages include highest risk of anterior knee pain, (which could become a chronic issue in a small percentage of patients), risk of breaking the knee cap (although very rare), larger incision, quadriceps weakness, and increased rates of arthritis under the knee cap. This graft is popular for high performance or professional athletes.

Quadriceps autograft

Quadriceps autograft is attractive due to the sturdiness of the graft, it has the option of including bone on one side (from the kneecap) and has less anterior knee pain when compared to patellar tendon autografts. Disadvantages include longer incorporation if using the tendon without the bone plug, higher risk of patella (kneecap) fracture if taking a bone plug, quad weakness, and it has not been used as long as hamstring or patellar tendon grafts, thus there is less data.

Hamstring autograft

Hamstring autograft is an attractive option for some because it has no associated anterior (front of the knee) pain and is harvested (removed from) a small incision. Disadvantages include no bony attachment which results in slower incorporation (the process of healing into the bone), hamstring weakness (of note: the hamstrings are a secondary stabilizer to the ACL), some evidence of slightly higher re-rupture rates when compared to quadriceps and patellar tendon autografts, and the possibility of a softer end point.

Allografts

Allografts are pieces of tissue from a donor, which are frozen before being used in ACL reconstruction surgery. The chance of disease transmission from an allograft is extremely low—less than 1 in 16 million. Unlike the three autograft options, allografts don’t require additional surgery to remove tissue from the patient, but they do take longer to fully integrate into the knee. Allografts are also more expensive since they come from a donor rather than the patient’s own body. Studies suggest that allografts might have a higher risk of re-tearing in athletes under 19. However, for people over 40 who engage in low-impact activities, allografts are a good option, offering similar success rates to autografts.

As you can see, each graft has its advantages and disadvantages. Discuss these options with your surgeon and share with them your goals for the future as well as your current activity level. Then, together find the one that fits you best, but remember there is no such thing as the PERFECT Graft.