ACL: Which graft should I choose?

Anterior cruciate ligament (ACL) reconstruction is a common procedure performed to restore stability after a ligament rupture. One of the most important decisions in planning surgery is choosing the right graft. The graft replaces the torn ligament, and the choice can influence recovery, strength and long-term performance.

There is no single ‘best’ graft for everyone. The right option depends on age, activity level, sporting demands, anatomy and personal priorities.

What types of graft are available?

In the UK, most ACL reconstructions use an autograft, meaning tissue taken from the patient’s own body. The three most common options are:

• hamstring tendon graft;
• patellar tendon graft;
• quadriceps tendon graft.

Each has specific advantages and considerations.

Hamstring tendon graft

This graft uses one or two tendons from the inner side of the knee. It's widely used and generally associated with less pain at the front of the knee after surgery.

It may be suitable for patients who:

• kneel frequently for work or sport;
• wish to minimise anterior knee pain;
• prefer a smaller incision.

However, hamstring strength can be temporarily reduced, and in some high-demand pivoting athletes, graft choice must be considered carefully.

Patellar tendon graft

This graft uses the central portion of the tendon connecting the kneecap to the shinbone. It has long been considered a strong and reliable option, particularly for high-level athletes.

It may be recommended for:

• competitive pivoting sports;
• young, high-demand athletes;
• those at higher risk of graft failure.

Some patients experience anterior knee pain or discomfort when kneeling, especially in the early stages of recovery.

Quadriceps tendon graft

This graft uses tissue from the tendon above the kneecap. It has become increasingly popular due to its strength and versatility.

It can offer:

• a thick, robust graft;
• potentially less kneecap pain than patellar tendon grafts;
• good suitability for revision surgery.

As with all grafts, recovery and outcomes depend heavily on surgical technique and rehabilitation.

Synthetic ACL grafts 

These are artificial, biocompatible materials, commonly polyester or polyethylene terephthalate (PET), designed to replace or augment a torn ligament without harvesting patient tissue. While offering benefits like no donor-site morbidity and faster rehabilitation, early versions had high failure rates. Modern, third-generation synthetic grafts aim to improve longevity through better tissue ingrowth, though long-term data is still yet to be gathered.

Modern examples include the LARS (Ligament Advanced Reinforcement System) and JewelACL.

Does graft choice affect recovery?

Initial recovery timelines are broadly similar regardless of graft type. However, certain differences may influence early symptoms, such as front-of-knee discomfort or hamstring weakness.

Return to sport is guided by strength testing, neuromuscular control and functional assessment rather than graft choice alone. Rehabilitation remains the most important factor in long-term success.

What about donor grafts?

In some cases, allografts, which use donor tissue, may be considered. These are more commonly used in revision surgery or selected patients. In young active individuals, autografts are generally preferred due to lower re-rupture rates.

How do I decide?

The decision should be made after detailed discussion with your knee specialist. Factors considered include:

• age and biological healing potential
• level and type of sport
• occupational demands
• previous knee surgery
• personal preference

There’s no universal answer. A personalised approach ensures that the chosen graft aligns with your goals and risk profile.

The most important factor

While graft choice matters, surgical precision and structured rehabilitation play an even greater role in long-term outcomes. A well-positioned graft combined with disciplined rehabilitation offers the best chance of restoring knee stability and returning safely to activity.

Discussing the options openly with your surgeon will help you make an informed decision tailored to your individual needs.