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ACL Graft Choices For Surgery

The reason why you need to use a graft is because when you tear your ACL doesn’t have good healing properties on its own. Therefore, the ligaments normally needs to be reconstructed, not repaired. In other words, we need to use a graft to replace the ligament. The grafts typically come from tendons in different areas of the body, and are broken up into two main categories: autografts & allografts. 

Autografts are grafts from your own body, such as a quadriceps tendon, patellar tendon, or Achilles’ tendon. In contrast, allografts are grafts that are from cadavers (dead or donor body). We will go over the pros and cons of the different types of grafts based on research and our clinical experience on the rehab side.


Patellar Tendon Graft


  • Strongest Graft & Gold Standard According to Research
  • Retention of a Native Tendon-Bone Interface
  • Graft-Host Integration via Bone-to-Bone Healing.
  • Reduced Rates of Re-Rupture of ACL in Comparison to Other Grafts
  • Quicker Complete Graft Integration in Comparison to Other Grafts
  • Faster return to play


  • Greater and More Persistent Anterior Knee Pain
  • Larger Surgical Incision
  • Risk for Patella Fracture

Quadriceps Tendon Graft


  • Decreased Anterior Knee Pain in Comparison to Patellar Tendon
  • Decreased Kneeling pain in Comparison to Patellar Tendon
  • Quicker return to play in Comparison to Patellar Tendon


  • Compromises Knee Extension Mechanism
  • Prolonged Quadriceps Muscle & Tendon Weakness
  • Could Lead to Quadriceps Tendinitis or Tendinosis

Hamstring Tendon Graft


  • Small Incision Size
  • No Compromise in Knee Extensor Mechanism
  • No Bony Disruption
  • Deceased Donor Site Morbidity in Comparison to Patellar Tendon Graft


  • Concern in Hamstring Weakness – Main Muscle Group that Assists the ACL
  • Greater Rates of Early Re-Rupture after ACL Reconstruction Compared with Patellar Tendon Graft


Allografts are grafts from a cadaver. The most common donor sites for a graft are the achilles’ tendon, patellar tendon, tibialis anterior, and hamstrings. Based on our experience, you typically do not have a choice in the particular allograft; as a result, we will group all of these allografts in one category.


  • Less Pain
  • Quicker Recovery to Everyday Function, 
  • Predictable Graft Size 


  • Longer Time to Return to Sports 
  • Higher Failure Rate

Key Points: 

  • Favorable for Multi-Ligament Knee Injuries 
  • Patients Older Than 40
  • Patient Preference 

Which Graft Should I Choose?

It depends! Some suggestions we have and steps we recommend you do when deciding are:

1) Do your research on surgeons. Look into the surgeon’s preference and comfortability with the graft type of choice.

2) Reflect on your goals. Take into consideration your age, basketball skill level, surgery date and stage of your career. For example, if you want to go back into active sports and you are younger we recommend autografts. If you’re older and return to high level sports aren’t your goals, look into an allograft or consider not having the ACL-Reconstruction. We will go over if surgery is necessary in a future blog article!

3) In our opinion, the most important consideration and achieving the best outcomes is the rehab component. Do your due diligence and find a physical therapist that will help improve your range of motion, neuromuscular control, strength, movement mechanics, and fits your style!


Bottoni CR, Smith EL, Shaha J, Shaha SS, Raybin SG, Tokish JM, Rowles DJ. Autograft Versus Allograft Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Clinical Study With a Minimum 10-Year Follow-up. Am J Sports Med. 2015 Oct;43(10):2501-9. doi: 10.1177/0363546515596406. Epub 2015 Aug 26. PMID: 26311445. Lin KM, Boyle C, Marom N, Marx RG. Graft Selection in Anterior Cruciate Ligament Reconstruction. Sports Med Arthrosc Rev. 2020 Jun;28(2):41-48. doi: 10.1097/JSA.0000000000000265. PMID: 32345925. Mouarbes D, Menetrey J, Marot V, Courtot L, Berard E, Cavaignac E. Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Outcomes for Quadriceps Tendon Autograft Versus Bone-Patellar Tendon-Bone and Hamstring-Tendon Autografts. Am J Sports Med. 2019 Dec;47(14):3531-3540. doi: 10.1177/0363546518825340. Epub 2019 Feb 21. PMID: 30790526.

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