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Graft Choices in ACL Surgery

The patient facing ACL reconstruction has several choices concerning the graft to be used.  Dr. Lowe will discuss in detail the Pros and Cons of each graft during your pre-surgical consultation in our office.  At this visit, Dr. Lowe will evaluate your specific injury, viewing diagnostic studies such as x-rays and MRI, and obtaining a patient history.  Once he discusses your injury, he will then review his recommendations for you as the patient to decide which option best fits you.

There are two different types of graft tissues that can be used in ACL reconstruction surgery.  Factors include any health risks enlightened to by the complete patient history form, the athlete's age, and what specific activities they will be returning to, i.e., sport, position, and participation level.

Autografts are harvested from the patient’s own tissue from another location in their body.  Allografts are harvested tissue from a donor.  Dr. Lowe is very specific with the type and style of allografts he uses during ACL reconstruction.  He solely uses grafts from MTF, the Muscularskeletal Transplant Foundation.

  • A bone-patellar tendon-bone autograft is one of the strongest grafts concerning the initial fixation.  This is due to the fact that there is bone on each end of the graft that is going into a tunnel in the bone.
  • Physicians have the most experience with using this type of graft.
  • Return to full athletic participation is typically quicker, usually within 5-6 months.

  • B-PT-B autografts are generally the most painful of the grafts post-operatively because harvesting the middle third of the patellar tendon along with a bone fragment from the distal pole of the patella and the tibia tubercle.
  • Has an increased chance for patellar tendonitis.
  • Because of the bone fragment harvested from the distal pole of the patella, there is an increased chance for a patella fracture.
  • Initial rehabilitation / activation of quadriceps is more difficult because one third of the connective tissue allowing for quadriceps activation is removed and used.
  • There is an increased incidence of patellar tendon pain and discomfort with kneeling.
  • There is an extra incision where the graft is harvested from.

(Semitendinosis and Gracilis tendons)

  • Hamstring autografts generally have the least post-operative pain associated with it.
  • Easier rehabilitation in regards to quadriceps activation occurs.
  • Most patients have a quicker return to Activities of Daily Living (ADLs).
  • The incision used to harvest the hamstring graft(s) is the same incision used to drill and place the fixation hardware.
  • The fixation is not as strong initially so caution is advised with rehabilitation.
  • General hamstring weakness is noted.
  • Return to full athletic participation is generally slower, usually 6-7 months.
  • There is no hamstring activation for at least the first four weeks in order to allow the harvest site to scar and heal down.
  • There is an increase incidence of hamstring strain / tenderness.
HS Autograft Harvest - Image 1 HS Autograft Harvest - Image 2 HS Autograft Harvest - Image 3
 drwaltlowe_HS-Autograft_image5.jpeg  drwaltlowe_HS-Autograft_image6.jpeg
HS Autograft Harvest - Image 4 HS Autograft Harvest - Image 5 HS Autograft Harvest - Image 6



  • No harvest morbidity occurs because the graft is donor tissue.
  • Allow for the fastest return to Activities of Daily Living (ADLs).
  • Allografts are the least painful post-operatively.
  • Allows for a smaller incision on the medial tibia.

  • Potential risk of viral transmission (HIV, hepatitis).  The chance of HIV infection from donor graft tissue is 1 in 1.8 million.
  • Return to full athletic activities is generally within 6-7 months.
  • Though small, there is a chance for some type viral transmission.  As with any surgical procedure, that chance is there.  There are also other risks involved with any surgical procedure.  Dr. Lowe or his representative will discuss those risks with you.
drwaltlowe_Achilles-Allograft_2.jpg drwaltlowe_Achilles-Allograft_1.jpg
Achilles Allograft Harvest - Begin Achilles Allograft Harvest - Final

Overall, each of the grafts are just as strong if you follow the specific protocol associated with graft type.  The differences between graft choices usually are with the fixation techniques.  The fixation is one of many factors that will determine how soon one progresses through their rehabilitation and allowed to return to full athletic participation.  Other factors that affect the return to participation include if there was any meniscal or articular cartilage injury that required additional procedures to be performed at the time of the ACL reconstruction.
Dr. Lowe will discuss with you in depth given your specific injury and what he feels is the best graft choice for you dependent upon what your goals are.

Dr. Lowe performs hundreds of ACL reconstructions each year on athletes from all over the United States and around the globe. On the average, Dr. Lowe utilizes Bone-Patellar Tendon Autografts approximately 50%, Achilles Allografts approximately 45% of the time, and Hamstring Autografts 5%.