ACL Graft Options
There is no single “best” graft for every ACL reconstruction. The most appropriate graft depends on factors such as age, sport, activity level, occupation, previous knee surgery, kneeling requirements, graft size, associated injuries and the surgeon’s assessment.
The three main autograft options are hamstring tendon, patellar tendon and quadriceps tendon. Each has potential advantages and trade-offs, and all can provide good outcomes when appropriately selected and combined with suitable rehabilitation.
For an overview of the operation itself, see ACL Reconstruction.
Key Points
- An ACL graft is the tissue used to replace the torn anterior cruciate ligament.
- An autograft uses the patient’s own tissue; an allograft uses donor tissue.
- Hamstring, patellar tendon and quadriceps tendon autografts are commonly used for ACL reconstruction.
- No single graft is universally superior for every patient.
- Graft selection should consider sport, age, occupation, kneeling demands, previous surgery and individual anatomy.
- Rehabilitation and return-to-sport preparation remain important regardless of graft choice.
What is an ACL graft?
An ACL graft is tissue used to create a new anterior cruciate ligament during ACL reconstruction.
The anterior cruciate ligament, or ACL, is one of the main stabilising ligaments inside the knee. In most conventional procedures, reconstruction replaces the damaged ACL rather than simply stitching it back together.
The graft is positioned through bone tunnels or sockets in the thigh bone (femur) and shin bone (tibia), where it is secured and gradually incorporates into the knee.
What is an autograft?
An autograft is tissue taken from another part of the patient’s own body and used to reconstruct the ACL.
Common ACL autografts include:
- Hamstring tendon
- Bone-patellar tendon-bone graft
- Quadriceps tendon
Autografts avoid the need for donor tissue and are often preferred in younger, more active patients.
What is an allograft?
An allograft is tendon tissue obtained from a donor rather than from the patient undergoing ACL reconstruction.
Because no tendon needs to be harvested from the patient, allograft reconstruction avoids pain and weakness associated with a graft-harvesting site.
However, donor grafts incorporate differently, and younger, more active patients have higher graft-failure rates than those with autografts.
Allografts may still have a role in selected patients, including some older or lower-demand individuals and certain revision procedures.
The decision depends on individual circumstances.
What are the main ACL graft options?
The main autograft choices are hamstring tendon, patellar tendon and quadriceps tendon.
Comprehensive Graft Comparison Table
| Graft Type | Tissue Source | Primary Advantages | Considerations & Trade-offs | Ideal Patient Profile |
|---|---|---|---|---|
| Hamstring Tendon | Semitendinosus (with or without Gracilis) | • Smaller incision • Less anterior knee & kneeling pain • Well-established technique | • Possible graft size variation • Temporary or persistent hamstring weakness | • Patients who kneel frequently for work • Low anterior knee pain tolerance |
| Patellar Tendon (BPTB) | Central 1/3 patellar tendon with bone blocks | Rigid bone-to-bone healing • Long history of success • Potentially lower failure rate in high-demand groups | • Risk of anterior knee pain • Kneeling discomfort • Temporary quadriceps weakness | • Young, high-demand athletes in pivoting sports • Cases where graft durability is paramount |
| Quadriceps Tendon | Partial tendon above kneecap (± bone block) | • Substantial tissue volume/strength • Less kneeling pain than BPTB • Highly adaptable size | • Temporary quadriceps weakness • Donor-site discomfort | • Athletes needing a strong, thick autograft • Primary or Revision reconstructions |
| Donor Allograft | Donor tissue | • No autograft harvest • Less donor-site pain • Faster initial surgical recovery | • Slower tissue integration • Higher failure rate in young, active patients | • Older or lower-demand patients • Select complex revision surgeries |
What is the best graft for ACL reconstruction?
The best ACL graft is the one that provides an appropriate balance of strength, failure risk, donor-site symptoms and functional requirements for the individual patient.
No graft is ideal in every situation.
Factors that may influence selection include:
- Age
- Sporting level
- Type of sport
- Previous ACL surgery
- Occupation
- Need to kneel regularly
- Existing anterior knee pain
- Hamstring requirements
- Quadriceps strength
- Previous tendon injury
- Graft size and anatomy
- Revision versus primary reconstruction
Recent evidence continues to show broadly comparable clinical outcomes between commonly used autografts, which supports individualised graft selection rather than declaring one universally superior. (PubMed)
What is a hamstring tendon graft?
A hamstring graft uses one or more tendons from the inner-back portion of the thigh to create the new ACL.
The semitendinosus tendon is commonly used and may be folded to create a multi-strand graft.
Potential advantages include:
- No bone block harvest
- Less anterior knee discomfort than patellar tendon grafts in some patients
- Smaller graft-harvest incision
- Well-established surgical technique
Potential considerations include:
- Temporary or persistent hamstring weakness
- Variation in tendon size
- Hamstring strength may be important for some athletes
- Graft failure risk may differ between patient groups
Hamstring grafts remain a widely used option.
Who may consider a hamstring graft?
A hamstring graft may be appropriate when avoiding anterior knee or kneeling pain is particularly important and sufficient tendon size is available.
It may be considered in patients who:
- Kneel frequently
- Have occupations where anterior knee comfort is important
- Prefer to avoid patellar tendon harvest
- Have no significant hamstring problems
- Have anatomy suitable for an adequate graft
The final decision should consider the patient’s sport, age and rehabilitation requirements.
What is a patellar tendon graft?
A patellar tendon graft usually uses the central portion of the tendon between the kneecap and shin bone, with a small bone block taken from each end.
This is often called a bone-patellar tendon-bone, or BPTB, graft.
Potential advantages include:
- Bone-to-bone healing within the tunnels
- Long history of successful use
- Strong fixation
- Potentially lower graft-failure risk in some high-demand groups
Potential disadvantages include:
- Pain at the front of the knee
- Discomfort while kneeling
- Temporary quadriceps weakness
- Rare problems involving the patellar tendon or kneecap
Who may consider a patellar tendon graft?
A patellar tendon graft may be considered for younger or high-demand athletes when graft durability is a key concern.
However, a patient whose occupation requires frequent kneeling may place greater importance on the possibility of anterior knee discomfort.
Graft selection should therefore balance sporting demands with everyday requirements.
What is a quadriceps tendon graft?
A quadriceps tendon graft uses part of the strong tendon above the kneecap to reconstruct the ACL.
It can provide a relatively large graft and may be harvested with or without a small bone block.
Potential advantages include:
- Substantial graft size
- Strong tissue
- Lower anterior knee or kneeling discomfort than patellar tendon grafts in some studies
- Useful option when other grafts have previously been used
Potential considerations include:
- Temporary quadriceps weakness
- Discomfort at the harvest site
- Less historical long-term data than hamstring or patellar tendon grafts
Use of quadriceps tendon grafts has increased considerably.
Who may consider a quadriceps tendon graft?
Consider a quadriceps graft when a large, strong autograft is desired or when hamstring or patellar tendon harvest is less suitable.
Potential situations include:
- Primary ACL reconstruction
- Revision ACL reconstruction
- Previous hamstring harvest
- Desire to reduce kneeling symptoms associated with patellar tendon harvest
- Need for a graft with substantial tissue volume
It is increasingly regarded as a mainstream ACL graft option rather than simply an alternative graft.
Hamstring versus patellar versus quadriceps tendon graft
All three autografts can provide good results, but their trade-offs differ.
| Consideration | Hamstring | Patellar Tendon | Quadriceps Tendon |
|---|---|---|---|
| Own tissue | Yes | Yes | Yes |
| Bone blocks | No | Yes | Sometimes |
| Long history of use | Yes | Yes | Increasing |
| Anterior knee pain | Usually less | More relevant | Usually less than patellar tendon |
| Kneeling discomfort | Usually less | More relevant | Usually less |
| Hamstring weakness | Possible | Minimal | Minimal |
| Quadriceps weakness | Possible indirectly | Possible | More directly relevant early |
| Graft size | Variable | Consistent | Often substantial |
| High-demand sport | Commonly used | Commonly used | Increasingly used |
| Revision surgery | Can be used | Can be used | Often useful depending on previous graft |
Which graft is best for athletes?
Athletes may benefit from different grafts depending on age, sport, level of competition and the specific physical demands of their position.
Important considerations include:
- Pivoting exposure
- Contact
- Sprinting
- Jumping
- Hamstring demands
- Kneeling
- Training volume
- Previous injury
Current research does not establish a single autograft as superior for every athlete.
A 2025 meta-analysis comparing patellar tendon and hamstring grafts found similar overall return-to-sport and rerupture rates. (PubMed)
This supports an individualised decision rather than selecting grafts solely according to sport.
Which graft is best if I kneel for work?
Hamstring or quadriceps tendon grafts may be considered when frequent kneeling is an important occupational requirement because patellar tendon harvesting can be associated with kneeling discomfort.
This may be relevant for occupations such as:
- Tradespeople
- Flooring workers
- Gardeners
- Mechanics
- Some healthcare workers
However, occupation is only one part of graft selection.
Sporting requirements, age and the overall knee injury also need to be considered.
Does graft choice affect ACL rehabilitation?
Yes. Graft choice can influence which muscles and donor-site symptoms require particular attention during rehabilitation.
For detailed rehabilitation information, see ACL Rehabilitation.
Does graft choice affect recovery time?
Graft choice can affect aspects of early recovery, but the overall ACL reconstruction timeline depends on much more than the graft alone.
See ACL Reconstruction Recovery Timeline for a detailed recovery overview.
Does graft choice affect return to sport?
Graft selection may influence strength recovery and donor-site symptoms, but return to sport should be based on functional readiness rather than graft type alone.
For return-to-sport criteria, see Return to Sport After ACL Reconstruction.
Does graft choice change in revision ACL reconstruction?
Yes. Revision ACL reconstruction may require a different graft because the tissue used in the first reconstruction may no longer be available.
Revision ACL reconstruction means another reconstruction performed after a previous ACL graft has failed or no longer provides sufficient stability.
Graft selection may depend on:
- Previous graft used
- Previous bone tunnels
- Available autograft tissue
- Patient age and activity
- Cause of the original graft failure
- Other knee injuries
Quadriceps tendon, patellar tendon, hamstring tendon or donor tissue may be considered depending on the individual situation.
How does Dr Hayes choose an ACL graft?
ACL graft selection should be individualised according to the patient rather than based on a routine “one graft for everyone” approach.
Factors to discuss with Dr Hayes can include:
| Question | Why it may influence graft choice |
|---|---|
| What sport do you want to return to? | Pivoting and high-demand sports may affect graft priorities |
| How old are you? | Younger active patients have higher reinjury considerations |
| Do you kneel regularly for work? | Patellar tendon harvest may cause kneeling symptoms |
| Is hamstring strength particularly important? | Hamstring harvest can influence strength recovery |
| Have you had previous ACL surgery? | Previous graft use may limit future options |
| Are other knee procedures required? | Associated surgery can influence planning |
| What are your rehabilitation goals? | Recovery priorities may differ between patients |
Frequently Asked Questions
Which ACL graft is strongest?
Laboratory strength alone does not determine the best clinical graft. Graft size, healing, fixation, surgical technique, rehabilitation and reinjury risk are also important.
Which graft causes the least pain?
Hamstring and quadriceps grafts may cause less anterior knee or kneeling discomfort than patellar tendon grafts, but donor-site symptoms vary between individuals.
Will the tendon grow back after graft harvesting?
Healing varies by tendon and harvesting technique. Some harvested tissues can regenerate to varying degrees, but the donor site may still have temporary or persistent strength or symptom differences.
Does one graft allow a faster return to sport?
No reliable evidence shows that choosing one graft alone allows a safely accelerated return to sport. Rehabilitation progress, graft healing, functional testing and sporting demands remain more important.
Can the graft tear after ACL reconstruction?
Yes. Any ACL graft can rupture following another significant injury. Risk depends on age, sport, rehabilitation, return-to-sport exposure and other individual factors.
