Graft Options for Ligament Surgeries / ACL

Jul 26, 2025 | Health

By Dr. Chirag Arora

Knee surgery with surgical instruments shown

FOR /ACL

ACL reconstruction requires a graft to replace the torn ligament. Grafts can be autografts (from the patient’s own body) or allografts (from a cadaver/donor). Below is a breakdown of all major options, including pros, cons, healing characteristics, and indications.

AUTOGRAFTS (From the Patient)

  1. Bone–Patellar Tendon–Bone (BPTB) Autograft
  • Source: Middle third of the patellar tendon with bone plugs from the kneecap (patella) and tibia.
  • Fixation: Bone-to-bone (strong and fast healing).
  • Advantages:
    • Excellent strength and stability.
    • Conventional gold standard for high-demand athletes.
    • Faster graft incorporation due to bone-to-bone healing.
  • Disadvantages:
    • (especially when kneeling).
    • Risk of patellar fracture or tendon rupture.
    • Longer recovery of quadriceps strength.
  • Indicated for:
    • Younger, high-performance athletes.
    • Contact sport athletes.

2. Peroneus longus (PL) Autograft

 

  • Source: Peroneus longus(PL) ligament, around the ankle
  • Fixation: Tendon to bone (strong healing).
  • Advantages:
    • Excellent strength and stability.
    • Becoming the new gold standard for high demand athelets.
    • Consistent and reproductible graft quality.
    • Great Healing potential.
  • Disadvantages:
    • Mild Risk of Paraesthisia around the ankle.
  • Indicated for:
    • Younger, high-performance athletes.
    • Contact sport athletes.

OUR PREFERENCE IN PRACTICE

3. Hamstring Tendon Autograft

  • Source: Semitendinosus (± gracilis) tendon from the inner thigh.
  • Fixation: Tendon-to-bone (slower than bone-to-bone).
  • Advantages:
    • Smaller incision and less pain at donor site.
    • Lower risk of anterior knee pain.
    • Good cosmetic outcome.
  • Disadvantages:
    • Tendon takes longer to heal into bone tunnel.
    • Inconsistent graft thickness especially in obese and short height individual.
    • Possible reduction in hamstring strength.
    • Slightly higher graft laxity risk in some studies.
  • Indicated for:
    • Individuals prone to anterior knee pain.
    • Cosmetic-sensitive patients.
    • Recreational athletes.

4. Quadriceps Tendon Autograft

  • Source: Central portion of the quadriceps tendon, with or without a bone plug from the patella.
  • Fixation: Soft-tissue-to-bone or bone-to-bone (if bone plug used).
  • Advantages:
    • Thick, strong graft (larger cross-sectional area).
    • Less donor site pain than patellar tendon.
    • Good for revisions or large patients.
  • Disadvantages:
    • Risk of quadriceps weakness.
    • Anterior knee pain
    • Less widely used, fewer long-term studies.
  • Indicated for:
    • Revision surgeries.
    • Patients with prior patellar or hamstring issues.
    • High-demand athletes needing strong graft.

ALLOGRAFTS (From a Donor)

  • Sources: Patellar tendon, Achilles tendon, tibialis anterior/posterior, hamstring tendon.
  • Fixation: Variable; depends on the tissue used.
  • Advantages:
    • No donor site morbidity (no extra incision or tissue removal).
    • Shorter operative time.
    • Less post-op pain.
    • Useful for multiligament reconstructions or revisions.
  • Disadvantages:
    • Slower biological incorporation.
    • Higher failure rate in young, active individuals.
    • Very small risk of disease transmission.
    • Reduced strength after sterilization (e.g., gamma irradiation).
  • Indicated for:
    • Older, less active patients.
    • Revision surgeries.
    • Multiligament .

Graft Comparison Table

Feature BPTB Hamstring Quadriceps PL

Healing

 Fast   Moderate      Moderate Fast
Strength High High Very High Consistent
Donor Site Pain High Low Moderate None
Anterior Knee Pain Common Rare Less common None
Return to Sport Rate High High

High

 

 High 
Graft Failure Risk (young)

Low

 

 Moderate Low

Very Low

 
Surgical Time

Moderate

 

 Short Moderate

Short

 

KEY CONSIDERATIONS FOR CHOOSING A GRAFT

  • Age: Younger patients may benefit more from autografts due to lower failure rates.
  • Activity level: High-level athletes often prefer PL/BPTB grafts.
  • Occupation: Kneeling professions (e.g., carpenters) may avoid BPTB due to anterior knee pain.
  • Cosmetic concerns: Hamstring or allograft has better cosmetic appeal.
  • Revision surgery: PL/Allografts or quadriceps grafts are often favored.
  • Multiligament injuries: Allografts may reduce surgical morbidity.

FINAL VERDICT (IN OUR PRACTICE)

OUR CHOICE IS PERONEUS LONGUS (PL) GRAFT IN HIGH DEMAND INDIVIDUALS OR HAMSTRING GRAFT IN LOW DEMAND/RECREATIONAL PLAYERS.

WE AVOID QUADRICEPS GRAFT (I/V/O KNEE PAIN POSTOP)

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