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Which ACL Graft Is Best?

One of the most common questions patients ask before ACL reconstruction is:

“Which graft should I choose?”

There is no single graft that is best for every patient.

The ideal graft depends on several factors, including your age, activity level, sporting goals, occupation, anatomy and personal preferences. During your consultation, Dr Ken Lee Puah will discuss the advantages and disadvantages of each option before recommending the graft that best suits your individual needs.

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What Is an ACL Graft?

During ACL reconstruction, the torn ligament is replaced with a tendon graft.

Over time, the graft becomes incorporated into the knee and gradually functions as a new ligament through a process known as ligamentisation.

The goal is to restore knee stability while allowing a safe return to daily activities and sport.

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Types of ACL Grafts

The most commonly used graft options are:

• Hamstring tendon autograft
• Patellar tendon (bone-patellar tendon-bone) autograft
• Quadriceps tendon autograft

Less commonly used options include donor (allograft) tissue in selected circumstances.

Feature	Hamstring Tendon	Patellar Tendon (BPTB)	Quadriceps Tendon
Commonly used	✓	✓	✓
Typical graft size	Good	Fixed	Often larger
Anterior knee pain	Low	Higher	Low
Kneeling discomfort	Low	Higher	Low–Moderate
Hamstring weakness	Temporary	No	No
Quadriceps weakness	No	Minimal	Temporary
Bone-to-bone healing	No	Yes	Sometimes*
Commonly chosen for	General patients	Selected high-demand athletes	Large graft requirement, selected primary/revision cases

*If harvested with a bone block

No graft is universally “best”. Each option has advantages and disadvantages, and the most appropriate graft depends on your age, activity level, sporting goals, anatomy and individual circumstances.

Hamstring Tendon Autograft

The hamstring tendon is one of the most commonly used grafts worldwide.

The graft is usually taken from one or two of the hamstring tendons through a small incision on the inner side of the upper shin.

Advantages

• Smaller incision
• Less pain when kneeling
• Lower risk of pain at the front of the knee
• Good cosmetic appearance
• Excellent long-term outcomes
• Suitable for many recreational and competitive athletes

Potential Disadvantages

• Temporary weakness of the hamstring muscles
• Slightly slower tendon healing compared with bone-to-bone healing
• Rare risk of graft stretching or re-tear

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Patellar Tendon Autograft

The patellar tendon graft uses the central portion of the tendon connecting the kneecap to the shinbone, together with small blocks of bone at each end.

This is often referred to as a bone-patellar tendon-bone (BPTB) graft.

Advantages

• Excellent initial fixation
• Bone-to-bone healing
• Long track record with excellent long-term results
• Often chosen for high-demand athletes

Potential Disadvantages

• Pain when kneeling
• Pain at the front of the knee
• Increased discomfort when squatting
• Small risk of kneecap fracture or patellar tendon problems

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Quadriceps Tendon Autograft

The quadriceps tendon has become increasingly popular in recent years.

It provides a thick, strong graft and may be harvested with or without a small bone block from the kneecap.

Advantages

• Large graft diameter
• Strong biomechanical properties
• Less kneeling pain than some patellar tendon grafts
• Useful for selected primary and revision ACL reconstruction

Potential Disadvantages

• Temporary weakness of the quadriceps muscle
• Larger incision than a hamstring graft
• Less long-term outcome data than hamstring or patellar tendon grafts, although evidence continues to grow

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What About Donor (Allograft) Tissue?

An allograft uses tendon tissue donated through a tissue bank.

Potential advantages include:

• No graft harvest from your own knee
• Shorter operating time
• Smaller surgical wounds

However, allografts may not be suitable for younger, highly active patients because some studies have reported higher graft failure rates in these groups.

They are more commonly considered in selected revision cases or when multiple ligaments require reconstruction.

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Is One Graft Stronger Than Another?

All commonly used autografts provide excellent stability when appropriately selected and combined with good surgical technique and rehabilitation.

Research has shown that patient selection, rehabilitation and return-to-sport decisions are often more important than simply choosing one graft over another.

Rather than asking which graft is universally “best”, the more useful question is:

“Which graft is best for me?”

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How Is the Right Graft Chosen?

Several factors are considered, including:

• Age
• Sporting activities
• Occupation
• Previous knee surgery
• Knee anatomy
• Associated injuries
• Personal preferences
• Surgeon experience

The graft recommendation is individualised for every patient.

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Does the Graft Become a New ACL?

Not immediately.

After surgery, the graft undergoes a gradual biological process called ligamentisation, during which it becomes incorporated into the knee.

This process takes many months and is one of the reasons rehabilitation continues long after the operation itself.

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Will Taking a Tendon Cause Long-Term Problems?

Most patients recover excellent function after tendon harvest.

Some temporary weakness may occur depending on the graft used, but structured rehabilitation is designed to restore strength and function.

Long-term problems are uncommon.

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Frequently Asked Questions

Which graft lasts the longest?

Current evidence suggests that all commonly used autografts provide excellent long-term outcomes when appropriately selected and combined with comprehensive rehabilitation.

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Which graft allows the fastest recovery?

Recovery depends more on rehabilitation, healing and individual progress than the specific graft used.

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Will I lose strength if my hamstring tendon is used?

Some temporary weakness may occur initially, but most patients regain good hamstring function through physiotherapy.

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Is a patellar tendon graft more painful?

Some patients experience more pain at the front of the knee or discomfort when kneeling compared with other graft options.

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Can the graft tear again?

Yes. A reconstructed ACL can be re-injured, particularly if returning to sport before adequate healing and rehabilitation.

Following a structured rehabilitation programme and appropriate return-to-sport testing helps reduce this risk.

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Related Pages

You may also find these pages helpful:

• ACL Reconstruction Singapore
• Can an ACL Tear Heal Without Surgery?
• ACL Tear Symptoms
• ACL vs Meniscus Tear
• ACL Rehabilitation
• Return to Sport After ACL Reconstruction

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Arrange a Consultation

Choosing the most appropriate graft is an important part of planning ACL reconstruction.

During your consultation, Dr Puah Ken Lee will discuss the available graft options, explain the advantages and disadvantages of each, and recommend an approach tailored to your individual anatomy, activity level and long-term goals.

The decision is made together, ensuring you have the information needed to make an informed choice about your treatment.

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Dr Puah is regularly invited to teach arthroscopic knee surgery

Book a consultation or contact the clinic via WhatsApp to get started

Book a consultation at 360 Orthopaedics, Mount Elizabeth Novena

ACL and meniscus tears are common but treatable. Early diagnosis and appropriate management can improve outcomes and prevent long-term problems.
Dr Puah Ken Lee is an orthopaedic surgeon in Singapore specialising in shoulder, elbow and sports injuries at 360 Orthopaedics, Mount Elizabeth Novena. Patients with instability, locking or pain in the knee after a sports injury are encouraged to seek specialist evaluation.