As of 2022, it is estimated that there are roughly 100,000 Anterior Cruciate Ligament Reconstructions (ACLR) performed each year. With these reconstructions, you have different graft options. A graft is simply yours or a donor’s tissue (in this case: the patellar tendon, quad tendon, hamstring tendon, or cadaver graft tissue) that is used to create your new ACL.
Before getting surgery, we always encourage our Made 2 Move athletes to know the different type of tissue options you have to choose from for your new ACL. At the Made 2 Move ACL performance lab, we see many athletes who are confused over the differences between grafts. Check out this quick clip from Stanford on different graft types.
There are many considerations that go into the type of graft you and your surgeon decide upon, the primary considerations being your age and lifestyle. Are you a 16 year old trying to play college soccer? Or maybe you are 55 year old who enjoys the weekend golf game and hikes with the family? These may lead to different graft choices. These factors, alongside your surgeon’s skillset and experience, will be considered in the selection of graft type.
For a deeper dive, check out this 2021 research review on graft types.
A few things to note before we dive into the different graft types.
This is not Made 2 Move advocating or endorsing a specific graft type over another- this is simply a brief rundown of the graft types. The decision over graft type is a conversation to be had with your surgeon.
Ask your surgeon: what are the pros and cons of each graft type? Retear rates? Their experience with the different grafts? Ultimately, your surgeon may be more experienced with a specific graft type and thus, will be less inclined to do an alternative type on you, even if it is the best option. Another valuable reason to get multiple opinions before heading into surgery!
Similar to rehab, ACL graft choice is incredibly patient specific. Just because your soccer buddy had a patellar tendon graft doesn’t mean that’s going to be the best fit for you. Stated perfectly by orthopedic surgeon Dr. Adam B. Cohen, “In general, each graft choice has value depending on the circumstances.There are pros and cons for each option and selection of the appropriate graft should be individualized.”
And finally, most studies do not control for the REHAB patients receive after their ACL reconstruction. Regardless of graft type, the rehab you receive after your ACL reconstruction is the single most important variable that will predict your outcomes, functionality, ROM, and strength. This is why Made 2 Move developed our performance lab specific to ACL rehabilitation- we had seen too many poorly rehabbed ACLs, so we created a solution!
What are the different types of ACL grafts?
There are 4 ACL graft types with 3 we most commonly see here at Made 2 Move. The 3 most commonly used are known as autografts, “auto” meaning self. Autografts are pulled from your own tissues. The 4th type of graft is an allograft, “allo” meaning other. Allografts are pulled from cadaver tissues.
The 3 grafts we most commonly see here at Made 2 Move are the patellar tendon autograft, hamstring autograft, and quadriceps tendon autograft, all of which will be unpacked below.
Patellar Tendon Autograft
The patellar tendon autograft is considered the “gold standard” in ACL reconstruction and has been around the longest. The patellar tendon (actually the patellar ligament because it connects two bones- patella and tibia) is a continuation of your quadriceps tendon. The patella tendon (ligament) connects your patella to your tibial tuberosity (that bony prominence on the top of your shin bone). It has been around since the 1960s and has the least rate of rerupture. This is a great option for younger or higher level athletes looking to return to sport.
This graft can also be referred to as bone-tendon-bone or BTB graft because the surgeon cuts little pieces of bone from the patella and tibia along with the middle ⅓ of the patellar tendon that will become your new ACL. “Woah, they’re cutting my BONE?!” you might be thinking. But these bone plugs are actually strategic, as it allows the body to respond and heal like it would to a fracture and brings a higher rate of vascularization to the new tissue.
Some downsides to this type of graft is that it can lead to anterior knee pain due to it being the tendon right over your kneecap. This is where individualization comes in- if your occupation or lifestyle requires you to spend a lot of time kneeling, this might not be the best choice for you.
Hamstrings Autograft
The hamstrings graft is another popular one, with one of its first appearances in the literature in 1934. This graft uses the semitendinosus (one of your 3 hamstrings) and sometimes the gracilis muscle (an adductor) to construct your new ACL. Because this only utilizes soft tissue (rather than bone plugs), it is suggested that it may have greater laxity than the patellar graft.
However, can still be a good option in some ACL reconstructions, as there is not as significant rate of rerupture as some of the other options, the site of the scar is smaller, and less anterior knee pain is typically reported. You will just have to nail your hamstring rehab with your Made 2 Move ACL Specialist!
With someone involved in a sport that requires high hamstrings demand, like sprinting or kicking, this may not be the #1 choice. The hamstrings act as a dynamic stabilizer for the knee and messing with these tendons can cause greater weakness. With someone who wants to limit the possibility of anterior knee pain post-operatively, this may be the route they choose.
Check out this 2019 study that followed patients 5 years after surgery and compared patellar vs. hamstring tendon autografts.
Quadriceps Tendon graft
This graft is a newer option but offers promising results. The quadriceps tendon lies above the knee cap, connecting the patella (knee cap) to the quadriceps muscles. This graft is strong and secure but does not have as much research as patellar tendon and hamstrings tendon. However, this 2020 review of research on quadriceps tendon reconstruction reported favorable outcomes.
Overall, the quadriceps tendon graft is going to offer more collagen and thickness than your patellar graft, and it comes without the anterior knee pain some experience after the patellar tendon graft. A caveat with this repair is the lesser research (since it is a newer method) and thus, less surgeons are confident in this procedure so it may not be as readily offered. At Made 2 Move, our ACL Specialist can help connect you with the right surgeon if this is the right choice for you.
New Kid on the Block: BEAR
While not an ACL reconstruction, there is a novel type of repair being utilized called the BEAR or Bridge-Enhanced ACL Reconstruction. This FDA approved procedure uses stem cells to allow the ACL to heal itself. This 2016 study followed 10 patients who received hamstring autograft vs. 10 patients that received BEAR in the 2 years following their operations.
Both groups had positive outcomes, with the BEAR group displayiong higher hamstrings strength. While this was a small sample size, the results are promising for the future of ACL repair!
There are some limitations to the procedure as Dr. Lau a BEAR trained Orthopedic Surgeon at Duke Health notes, “It has to take place within 50 days of the injury, and there must be sufficient ACL tissue remaining.” This is just to show that the research on ACL is always evolving. Do your research and ask your Made 2 Move ACL Specialist and your orthopedic surgeon all the questions!
Which graft should I choose?
Overall, functional outcomes can be similar for all graft types, and the choice is going to depend on your age and goals. Regardless of the type of graft you choose, there will be an extensive rehab process ahead of you. That’s what we are here for at Made 2 Move: to help you restore range of motion, strength, and get back to what you love doing. Ready to rehab your ACL the right way? Reach out to frontdesk@made2movept.com today to set up an ACL Consultation.