6 key ACL graft options leading into surgery – which type is best for you?

If the decision is made to have ACL surgery, then there are some ACL graft options you might want to avoid!

ACL Graft Options and reconstruction surgery

  • The majority of ACL tears are from non-contact injuries. You don’t have to be on a sports field to hear the dreaded pop.  
  • For those who choose to have an ACL reconstruction, where to harvest the new graft is an important question. In this article, we discuss 6 key ACL graft options you should understand before undergoing an ACL operation.

Can the new ACL graft fail?

  • The research suggests that ACL graft types taken from your own body tissue have historically had the lowest retear rates amongst athletes returning to sport.
  • But even if you do everything right the research indicates that about 10 to 15% of ACL reconstructions will fail.
  • Whilst other graft options such as LARS and allografts have been less successful than grafts taken from your own body. For this reason, many surgeons will recommend avoiding these options.
  • ACL graft choice preferences will vary from surgeon to surgeon and the type of ACL graft chosen for an ACL operation will often come down to your surgeon’s preference.
  • The choice of surgeon can also impact the success of ACL surgery.  You should choose a surgeon who is highly experienced performing multiple ACL reconstructions every single month and has a good reputation in the community. 

Where do you start with choosing the right ACL graft?

ACL Graft options

  • So which ACL graft type should a person choose if they elect to undergo ACL reconstruction surgery?
  • Firstly, it is important to note that one of the first things to consider is the decision of whether or not to have ACL surgery in the first place.  ACL reconstruction surgery is an elective procedure.
  • Electing to have ACL surgery should be discussed carefully with your surgeon and trusted practitioner.
  • There are also some other important decisions that you need to make about your surgery.
  • This includes choosing a trusted and highly credentialled surgeon to perform the reconstruction surgery, the ACL graft type and the most appropriate timing for the surgery.
  • In terms of ACL graft options, one of the key points to note is that surgeons often prefer to take tissue from your own body to harvest the ACL graft.
  • This includes the patella, hamstring and quadriceps tendon.
  • Yet the surgeon’s preference will often be linked to what they have seen to be successful in their own past experiences.
  • As a result, one surgeon’s preference for a particular type of ACL graft can be different from another surgeon’s.  If you disagree with the surgeon’s preference then do not hesitate to get a second opinion.  

Where do ACL grafts get harvested from?

Many surgeons prefer to take tissue from your body to create the new ACL graft as the success rates have historically been the highest.  This includes the:

    • Hamstring Tendon Autograft: Surgeons use a hamstring tendon from the back of the patient’s thigh
    • Patellar Tendon Autograft: In this procedure, surgeons use a portion of the patient’s tendon that connects the kneecap and shin, and
    • Quadriceps Tendon Autograft: Taking a portion of the quadriceps tendon is another option for surgeons to create grafts.
  • As discussed below, each of these 3 autograft options has there pros and cons.
  • 3 further graft options that you should be aware of include donor grafts, LARS and bridge enhanced ACL repair (BEAR).
  • BEAR is a more recent approach to ACL repair which requires more research to evaluate the effectiveness of the procedure.

How many ACL tears are there in a year and what are the success rates?

  • In terms of statistics, according to the Boston Children’s Hospital there are approximately 400,000 Anterior Cruciate Ligament injuries every year in the United States.
  • The statistics indicate that the re-tear rate for ACL reconstructions can be as high as 20% for teens and up to 80% of patients will develop arthritis 15 to 20 years after surgery.

6 Key ACL Graft Options

  • Once the decision is made to have ACL reconstruction surgery traditionally most people opt for either a patella or hamstring graft to replace the severed ACL graft.
  • In more recent times the quadriceps graft has started to gain in popularity as an alternative option.

ACL graft option Number 1 – Patella tendon

  • In the patella tendon graft procedure, surgeons use a portion of the patient’s tendon that connects the kneecap and shin.
  • Many surgeons prefer to use a patella tendon graft as it closely resembles the torn ACL.
  • A patella tendon graft is approximately the same length as the ACL and the bone ends of the graft can be placed into the bone where the ACL attaches.
  • The disadvantages of using a patella tendon graft are that there is potential for risk of experiencing pain at the front of the knee.  In particular where the patella tendon graft was taken.

ACL graft option Number 2 – Hamstring tendon

  • Surgeons use a hamstring tendon from the back of the patient’s thigh.
  • The hamstring tendon is where two of the tendons of the hamstring muscle are effectively removed and bundled together to create a new ACL graft.
  • One of the key advantages of using a hamstring tendon graft is it avoids the common problem associated with using a patella tendon graft where pain is known to occur at the front of the knee.
  • This is not a problem with hamstring tendon grafts as the incision to obtain the graft is smaller and overall the pain is thought to be less.
  • One of the key disadvantages with hamstring tendon grafts is it takes a longer period of time for the graft to become rigid and therefore people often need longer to be protected whilst the graft heals into place.
  • Further, hamstring grafts have in some studies shown to result in less strength of the hamstrings after surgery.

Patella tendon v hamstring tendon autograft

  • Whilst patella tendon revision rates are thought to be lower than hamstring tendon grafts, it is clear that both graft options have low revision rates and are excellent choices for ACL grafts.
  • In other words, both the patella and hamstring tendon grafts are well regarded for their use in ACL reconstruction surgery 

ACL Graft Option Number 3 – Quadriceps tendon

  • The quadriceps tendon tissue has become more popular in recent times and is now considered to be a genuine alternative to the patella and hamstring grafts.
  • There are a number of reasons why you might opt for a quadriceps tendon graft including:
    • You are concerned about developing post surgery patella tendonitis.
    • You are involved in kicking sports and therefore do not want a hamstring tendon graft as you are concerned about weakening your hamstrings.

ACL Graft Option Number 4 – Allograft Donor Tissue

  • An Allograft is tissue (also referred to as Cadaver tissue) such as a ligament, bone or tendon that is surgically implanted from one person to another.
  • Whereas an autograft takes tissue from one part of your own body for transplant to another part of your body.
  • Allografts can be used in a number of different medical procedures such as shoulder or ankle repairs, plus also used as an ACL graft option for reconstructions.
  • The allograft tissue can come from death where a person has consented (or consent is provided through family) to donate his or her tissue to another individual to enhance their quality of life.
  • According to some sources, there are approximately 1 million allograft medical procedures in the United States every year and have been used for approximately 150 years.
  • Some studies have shown that an allograft may not be as strong as a patient’s own tissue leading to an increased risk of re-tear.
  • For many patients however the strength of an allograft may be sufficient to meet their demands.
  • Patients may elect to have an allograft from a donor because they are told by some physicians that there is less pain and they can return to sport sooner.
  • However, you need to be cautious.  When it comes to an ACL reconstruction the research suggests that donor tissue has a significantly higher failure rate when compared to tissue taken from your body.
  • In some cases where a donor graft has been used to create an ACL, the body has essentially rejected the tissue and revision surgery has been required.

ACL Graft Option Number 5 – Ligament Augmentation and Reconstruction System (LARS)

  • LARS which stands for Ligament Augmentation and Reconstruction System is effectively the use of artificial polyester material to replace an injured ACL graft.
  • When it comes to ACL reconstructions for professional sports athletes, one of the most hotly debated topics in media circles is whether or not an athlete is using LARS or the traditional patella tendon or hamstring tendon graft options.
  • The key advantages of using LARS are the significantly reduced ACL recovery times which allow athletes to return to sport in a quicker time frame.
  • However, there are some concerns around the failure rates of LARS which has promoted many surgeons to continue using the traditional autograft options rather than LARS for their patients.

ACL Graft Option Number 6 – Bridge Enhanced ACL Repair

  • Bridge Enhanced ACL Repair (BEAR) is a relatively new technique which uses stitches and injection of the patients own blood to stimulate the healing of a torn ACL.
  • BEAR stimulates a torn ACL to heal itself and eliminates the need for a tendon graft.
  • It is hoped that this method which aims to repair the existing torn ACL rather than replace the graft, will reduce the time it takes to recover from ACL surgery.
  • Plus possibly reduce the long term risk of arthritis in the injured knee.
  • However, currently, BEAR is still a relatively new procedure and has been trialed on a limited number of patients and animal models.
  • The goal of current and future studies is to determine whether or not this new technique is as reliable as a reconstruction for patients.
  • Plus to determine the levels of revision rates compared to the traditional ACL autograft option.

Do you need to repair your torn ACL?

  • Not everyone who injures their ACL needs to have ACL reconstruction surgery to replace the torn graft.
  • There is normally no urgency to make a decision to have an ACL operation unless significant instability is evident.
  • Not having ACL surgery is a very realistic option that people do choose if the circumstances are right for them.
  • There are instances where your surgeon will recommend not having an ACL reconstruction.
  • For example, for older and non-active people, surgeons may choose not to repair the ACL at all, but rather recommend a rehabilitation program that includes strengthening and mobility exercises.
  • Click here to find out more about whether or not you will require ACL reconstruction surgery.

How is the new ACL graft inserted into your knee?

  • An ACL reconstruction is performed by an orthopedic surgeon and takes one to two hours to complete.
  • The procedure is typically performed through arthroscopy which includes preparing the new graft, removing the torn ligament, and attaching the new tendon to bone for better fixation and healing.
  • The benefits of arthroscopic procedures include ease of viewing and manipulating the knee, smaller incisions, ability to complete surgery at the time of diagnosis, and fewer risks compared to open procedures.
  • ACL reconstructions aim to produce a result that is close to the original structure as possible.
  • Better techniques now mean patients spend less time in hospital however once the nerve block wears off you will still need pain killer medication.


  • When it comes to ACL surgery, the choice of ACL graft type is an important consideration because statistically the graft type can impact failure rates and your the duration of your ACL recovery timeline
  • Choosing the right ACL graft is even more important if you intend to return to playing a high level of sport which requires a lot of pivoting and twisting movements of the knee.
  • The selection of ACL graft type often comes down to your surgeon’s preference which can vary from surgeon to surgeon.  The preferred graft type for surgeon’s continue to evolve over time.
  • Many surgeons prefer to take tissue from your own body to create the new ACL graft as the research indicates that these options have lower failure rates. This includes the patella, hamstring and quadriceps tendon.
  • In terms of stability and functional outcomes each of these 3 options will work if performed by a good surgeon. Yet each option has its own pros and cons which you should discuss with your surgeon and physical therapist.
  • Allografts or donor grafts whilst can also be popular amongst some surgeons because they save surgeons time but are not ideal because they have comparatively higher failure rates, especially in young people.
  • Another option is the possibility of using stem cells to grow your own ACL.  This is a relatively new procedure which eliminates the need for a tendon graft. However, using stem cells requires more research to determine if it works and is durable.
  • It is advisable to talk to multiple surgeons and therapists to understand what is the right ACL graft option for you.
  • Importantly, you also need to find a good surgeon who performs many ACL reconstructions each month. Speak to your local physical therapist or doctor for assistance & recommendations.  It can never hurt to get more than one opinion. 
  • If the decision to have ACL surgery is made, then an intensive and robust rehabilitation including adherence to a specific exercise program is required.      

Good Luck With Your ACL Injury Rehabilitation!

Click the link below for a copy of your Free ACL recovery checklist or go to:



ACL Graft Options Video

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