ACl tendon choices for surgery

getting acl surgery? here is a comprehensive guide to understand your tendon choices – what it is, the pros and cons to help you choose.

What is the acl?

The anterior cruciate ligament (ACL) is one of the major ligaments in the knee joint that connects the thigh bone (femur) to the shinbone (tibia). Its primary role is to provide stability to the knee, preventing excessive forward movement of the tibia in relation to the femur. However, ACL injuries can occur due to various reasons such as:

  1. Non-contact movements: ACL injuries often occur during activities that involve sudden changes in direction, pivoting, or landing from a jump. Examples include abruptly stopping, cutting movements, or twisting the knee while the foot is fixed on the ground.
  2. Direct impact: In some cases, ACL injuries can result from direct contact or collisions, such as during sports like football or soccer, where players may collide with each other or experience a blow to the knee.

When the ACL is injured, it can result in a partial or complete tear of the ligament, leading to knee instability, pain, swelling, and a decreased range of motion.


If you are going for surgery, here are some common tendon options available:

When ACL reconstruction surgery is necessary, there are several tendon options available for grafting. The most commonly used tendon choices include:


1. Autograft

Autografts involve using a patient’s own tissue for reconstruction. The two primary autograft options for ACL surgery are:

  • Patellar Tendon Autograft (PTA): This involves using a portion of the middle patellar tendon, along with bone plugs from the shin and kneecap.
  • Hamstring Tendon Autograft: This involves using a portion of the hamstring tendons located at the back of the thigh.

Pros of autografts

  • Better graft incorporation: higher chance of complete integration and natural healing as it uses the patient’s own tissue.
  • Potentially stronger graft, particularly the patellar tendon autograft has associated with initial stability and fixation strength.
  • Lower risk of disease transmittion since the tissue is from the patient’s own body.


Cons of autografts

  • Donor site morbidity. Harvesting the graft the patient’s body may cause pain discomfort and potential complications at the donor site such as patellar tendonitis in the case of patellar tendon autograft.
  • Weaker hamstring strength. Hamstring tendon autograft may result in hamstring weakness and potential loss of strength in activities like knee flexion and hamstring function.


2. Allografts

Allografts involve using tissue from a donor, typically a deceased person. Allograft options for ACL surgery include:

  • Patellar Tendon Allograft: This involves using a patellar tendon from a donor.
  • Hamstring Tendon Allograft: This involves using hamstring tendons from a donor.

Pros of allografts

  • No donor site morbidity: Since the tissue is obtained from a donor, there is no additional morbidity or pain at the donor site.
  • Less invasive: Allograft surgery may involve a less invasive procedure, as it doesn’t require harvesting tissue from the patient’s own body.
  • Suitable for revision surgery: Allografts are often considered in cases where previous ACL reconstruction has failed or when multiple ligaments need to be reconstructed.

Cons of allografts

  • Disease transmission risk: Although rare, there is a minimal risk of disease transmission, such as bacterial or viral infections, despite thorough screening and processing of the graft.
  • Lower initial fixation strength: Allografts may have a slightly lower initial fixation strength compared to autografts.
  • Potential immune reaction: In some cases, the patient’s immune system may react to the allograft tissue, leading to graft failure or rejection.


3. Synthetic graft

Synthetic grafts are made of artificial materials and are less commonly used compared to autografts and allografts. They are usually reserved for specific cases or when other graft options are not suitable. Common synthetic graft options include: 

  • Polyethylene terephthalate (PET) grafts: These are braided or woven synthetic grafts.
  • Poly L-lactic acid (PLLA) grafts: These are absorbable synthetic grafts.

The choice of tendon for ACL reconstruction depends on various factors such as the patient’s age, activity level, surgeon’s expertise, and individual preferences. Each tendon option has its own advantages and disadvantages, which should be carefully considered.


Pros of synthetic grafts

  • No donor site morbidity: Synthetic grafts eliminate the need for harvesting tissue from the patient’s own body, reducing donor site morbidity.
  • No disease transmission risk: Synthetic grafts are not associated with the risk of disease transmission.

Cons of synthetic grafts

  • Lower long-term success rates: Synthetic grafts have generally shown inferior long-term success rates compared to autografts and allografts.
  • Increased risk of graft failure: Synthetic grafts may have a higher risk of re-rupture or failure compared to autografts and allografts.
  • Limited evidence and long-term data: The long-term performance and outcomes of synthetic grafts are still being studied, and there is limited evidence available on their effectiveness and durability



ACL reconstruction surgery offers various tendon choices, including autografts (such as Patellar Tendon and Hamstring Tendon), allografts (such as Patellar Tendon and Hamstring Tendon), and synthetic grafts (such as PET and PLLA).

Each option has its own advantages and disadvantages, and the selection should be based on factors such as patient characteristics, surgeon expertise, and individual preferences. Consultation with a qualified orthopaedic surgeon is essential to determine the most suitable tendon choice for ACL reconstruction surgery. 

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