Choosing a new graft for ACL reconstruction: Things to consider

A correct understanding of the knee’s anatomy is crucial when choosing the right type of graft for Anterior Cruciate Ligament (ACL) reconstruction.  ACL reconstruction relies heavily on the graft type. Statistics show that approximately 20% of teens suffering ACL reconstructions experience re-tears, and 80% develop arthritis after 15 or 20 years of surgery. The type of graft affects a patient’s success rate of the procedures and their recovery timeline. More so if their plans include returning to sports that require pivoting and twisting movements. 

The classification of grafts includes autografts (harvesting bone from one’s own body) and allografts or also referred to as donor grafts (that is to harvest bone from another person or cadaver). Another option is Ligament Augmentation and Reconstruction System, or LARS (artificial grafts). 

In the first category of the classification, namely autografts, there are three types, namely the patellar tendon, hamstring tendon, and quadriceps tendon.

The second category is the allograft or donor graft. This is for example, when the orthopaedic surgeon uses a graft from a child’s mother or father during paediatric ACL reconstruction.

However, the preferred choice remains harvesting tissue from the patient’s own body (autograft) to create the new ACL graft. Research shows that these options have lower failure rates. Let’s examine each of these types a little closer. 

Historically the patella tendon graft is a very popular, reliable and safe graft for ACL reconstruction. This graft involves harvesting a piece of bone from the patient’s own kneecap. “We create a new ACL using a 1cm central portion of the patellar tendon and bone from the tibia. We then drill into the femur and tibia where the ACL anatomically attaches, and pulls the graft into these tunnels to create the knee ligament,” explains orthopaedic surgeon Hannes Jonker. “The patella tendon graft closely resembles a torn ACL, and it is almost the same length as an ACL, which is beneficial to the patient,” confirms Dr Jonker.  However, pain may develop at the site where the surgeon harvested the graft (donor site morbidity).

It is also possible to reconstruct the ACL using the hamstring tendon (from the back of the thigh). An orthopaedic surgeon removes two of the tendons of the hamstring muscle and bundle it together to create a new ACL graft. “By folding these tendons four to six times over, we create a graft with a 9 to 10mm diameter, just like the original ACL”, says Dr Jonker. Then the orthopaedic surgeon pulls it through the tunnels in the femur and tibia. Orthopaedic surgeons have used hamstring grafts for decades with a high rate of clinical and biomechanical success. The incision is smaller and patients experience less pain after the surgery. An advantage with the newer techniques is to also insert an internal brace with the ligament that allows exhilarated rehabilitation, thus protecting the graft while it heals.


A third option is the quadriceps tendon graft. If you are playing any kicking sports, like soccer or football, you might opt for the quadriceps tendon graft instead of a hamstring tendon graft as you do not want to weaken your hamstrings. Newer graft harvest techniques and instrumentation allow for easy, safe, and reliable graft size harvesting. The quadricep tendon is a thick, strong tendon above the patella (kneecap). The advantages of this graft include the size, firmness, and reliability like that of the patella tendon graft but without the risk of anterior knee pain.


Then there is the option of the second category, namely the allograft (cadaver) or donor tissue (for example tissue from a family member) such as a ligament, bone or tendon which an orthopaedic surgeon surgically implants from one person to another. Some studies show that an allograft may not be as strong as a patient’s own tissue and may lead to an increased risk of re-tear. Orthopaedic surgeons may recommend this graft type for lower demand patients or senior patients. A slightly shorter surgery time and a reduction in pain after surgery are examples of the benefits of using an allograft tendon.  It is evident in some donor graft cases that the patient’s body rejects the tissue, requiring revision surgery.


The Ligament Augmentation and Reconstruction System, or LARS involves the use of artificial polyester material to replace an injured ACL graft. Although LARS significantly reduces the recovery time of ACL, which allows athletes to return to sport sooner, there are concerns regarding the failure rates of LARS which increases the popularity of patella tendon and hamstring tendon autografts.



“By reconstructing the ACL, we aim to produce a structure that is close to that of the original ligament, The preferred choice remains harvesting tissue from the patient’s own body (autograft) to create the new ACL graft. Research shows that the autografts have higher success rates. This includes the patella-, hamstring- and quadriceps tendons, ” says orthopaedic surgeon, Dr Hannes Jonker.


It is vital that you visit an orthopaedic surgeon after suffering an ACL injury. Only your orthopaedic surgeon can diagnose the severity of the tear and determine the right treatment plan for you. By obtaining the right information from your doctor and following their recommendations, you can determine what graft is the right fit for you.

Written by Elmari Snoer, BusinessBrainz

Interview with Orthopaedic Surgeon, Dr  Hannes Jonker



Notice: Undefined index: eael_ext_toc_title_tag in /home/orthojza/public_html/wp-content/plugins/essential-addons-for-elementor-lite/includes/Traits/Elements.php on line 526