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Knee & Shoulder Doctor

​ACL Graft Ch​​oices
Patients have multiple graft choices in ACL reconstruction. The pros and cons of each graft will be discussed at your office visit. Briefly, there are two types: AUTOGRAFT tissue (your own tissue) and ALLOGRAFT tissue (donor tissue).

Within each of these groups are subtypes. Which graft type to choose depends on a variety of factors including the patient’s age, medical history, other knee injuries, what activities the patient will return to, duration to return to work or sport, and level of participation.


This type of graft is harvested often from the patient’s own tissue. Typically, these include the bone-patellar-bone tendon (BTB), hamstring (HS), or quadriceps garafts.

This type of graft is harvested from a donor. We obtain grafts almost exclusively from RTI (Regeneration Technologies Inc) Biologics or MTF (Musculoskeletal Transplant Foundation).

​​​​​Subtypes of Gr​​afts

​​​​Bone-Patellar-Bone (BTB) Autografts​​​

  • Good fixation and more predictable healing pattern because of bone to bone healing​
  • Full return to sports, typically around 6 months
  • Orthopedic surgeons have the most experience with this graft​


  • Increased risk of patellar tendonitis and possible patellar fracture
  • Increased risk of​ anterior knee pain and difficulty with kneeling​​​
  • Typically, the most painful of grafts because of harvesting procedure
  • Reactivation of the quadriceps during postoperative course takes more time
  • ​Larger incision on leg​

Hamstring (HS) Autografts (Semitendonosis and Gracilis Tendons) 

  • Less pain postoperatively than BTB
  • Quicker quadriceps reactivation
  • No additional incisions

  • Soft tissue fixation not as strong
  • Soft tissue healing to bone more unpredictable
  • General hamstring weakness does occur and increased risk of hamstring strain and/or tenderness (important for certain sports)
  • No active hamstring exercises for 4-6 weeks after surgery

Allografts (BTB Tendon, Hamstring Tendon, Achilles Tendon, Quadriceps Tendon)

  • Decreased morbidity since no need to harvest graft
  • Quicker return to activities of daily living (ADLs)
  • Less painful postoperative course
  • Smaller incision on leg

  • Potential infection risk, such as Hepatitis or HIV. (Current reported risk of HIV infection from donor tissue is less than 1 in 1 million)
  • Potential risk of graft laxity (ligament stretching)
  • Return to sport at 7 - 9 months

In summary, each of the grafts has pros and cons. Each graft is as strong or stronger than the native ACL. They have comparable strength as long as the specified protocol is followed. Graft fixation is one factor that has an important role in determining rehabilitation progression and ultimate return to sports. Other factors include articular cartilage or meniscal injury that may have required treatment at your ACL reconstruction.

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