There are three common grafts for ACL surgery taken from your OWN body: hamstring, patellar tendon (from the front of the knee) and quadriceps tendon (from above the kneecap). A graft from your own body is generally better than donor tissue, especially if you’re young.
Between the three, the research doesn’t agree on which one fails least. Where they clearly differ is the leftover soreness at the site the graft was taken from.
Your own tissue or donor tissue?
- Your own tissue (autograft) is the strong recommendation from US orthopedic guidelines
- Donor tissue (allograft) fails more often in young, active people. In under-19s, one study found about 1 in 4 donor grafts failed, against about 1 in 12 patellar tendon grafts
- Donor tissue can make sense for some older, less active people, or for revision surgery. That’s a conversation with your surgeon
The three options
- Hamstring: less pain at the front of the knee and easier kneeling. Hamstring strength takes longer to come back, and no weighted hamstring curls for about 8 weeks. Some large registries show slightly more re-operations, especially in young athletes
- Patellar tendon: a strong graft with bone at each end, which heals in well. The most kneeling pain and front-of-knee soreness afterward, affecting up to about 3 in 10 people
- Quadriceps tendon: the least trouble at the graft site in the studies. Growing in popularity. Longer-term data is still building
The grafts differ less in how often they fail than in what they leave behind.
Why the studies disagree
- Big national registries track tens of thousands of real-world operations by many surgeons. Some show hamstring grafts needing more redo surgery than patellar tendon
- Controlled trials compare grafts under tighter conditions, and mostly find no clear difference in failure
- Both are real evidence. Your surgeon’s own experience with each graft is a legitimate part of the choice
Graft-site soreness
Some leftover trouble at the graft site is very common, affecting nearly half of people in some form. The order is consistent across studies:
- Quadriceps tendon: least
- Hamstring: in between
- Patellar tendon: most, especially pain when kneeling
If your job, faith or hobby involves a lot of kneeling (flooring, plumbing, gardening, prayer, martial arts), tell your surgeon before the operation.
Questions to ask your surgeon
- Which graft do you use most, and why for me?
- How does my age and sport change the choice?
- What will the graft site feel like in a year?
- Does the graft change my rehab rules?
- Will anything else be repaired at the same time, like a meniscus, and how does that change recovery?
Don’t wait too long to decide
- If you’re having surgery, guidelines favor doing it earlier rather than later
- The risk of damaging the meniscus and cartilage rises within about three months of living with an ACL-deficient knee, especially if it keeps giving way
- Use the wait well. Get the knee straight, the swelling down and the thigh muscle strong before surgery. It makes the recovery easier
For what happens after surgery, see ACL recovery month by month and return to sport after ACL surgery.
Get it checked before surgery if
- The knee locks, catches or won’t fully straighten. A torn meniscus may be blocking it
- The knee keeps giving way in daily life
- Swelling returns after activity
Your own tissue over donor tissue. Beyond that, choose with your surgeon, and think about kneeling.