Although the initial bio-mechanical properties of the ACL grafts play a major role in the success of ACL reconstruction, the disadvantage of having to harvest graft tissue from a particular area, the initial fixation strength, the healing potential as well as the long term outcome  all have to be considered when choosing your graft.

The Gold standard graft remains the 4x Hamstring graft :


Hamstring Graft

Advantages  :

  1. Low incidence of donor site complications and morbidity
  2. More closely matches the stiffness of the normal ACL
  3. High initial graft strength (double that of normal ACL)

Disadvantages :

  1. Hamstring bruising and pain in first 10 days and rarely at around the 6 week mark
  2. Tendon to bone healing slower than bone to bone healing ( with current fixation techniques this is not relevant)
  3. In rare cases hamstring weakness


Patella Tendon Graft

The old  gold standard used to be the Patella Tendon graft. This was mainly due to the high initial fixation strength and stiffness.

There is however a long list of disadvantages when using Patella Tendon. Therefore I only use this in very select cases :


  1. High initial tensile fixation strength
  2. High stiffness
  3. Due to the above properties it requires less postoperative protection . This can be advantageous in selected chronic cases and revision cases


  1. Increased incidence of donor site complications (donor site pain, patellar tendinitis, patella tendon rupture, patella fracture, extension weakness, patello femoral pain, inability to kneel and shortening of the Patella Tendon due to scarring )
  2. Much stiffer than normal ACL
  3. Associated with a greater incidence of Knee stiffness
  4. Higher incidence of Osteoarthritis


Quadricepts Tendon Graft

The Quadriceps tendon has similar good outcomes compared to Patella Tendon and Hamstring Tendon grafts. I recommend this graft for revision and also primary cases.


  1. High initial tensile strength
  2. Reduced morbidity compared to Patella Tendon
  3. Similar strength compared to Hamstring Tendon and Patella Tendon


  1. Visible scar on top of the knee



The use of soft tissue allograft has grown in popularity to accommodate a wide range   of ligament reconstruction procedures. In select cases this can be an excellent choice , the advantage being that no graft tissue has to be harvested, there is no graft harvest related morbidity and good long term outcomes have been reported in the literature (using  non- irradiated fresh frozen grafts).


  1. No donor site morbidity
  2. Unlimited size


  1. Disease transmission . HIV estimate 1 in 1,5 million
  2. Mildly higher failure rate compared to Autografts


Prosthetics (LARS)

In my opinion there is no place for Prosthetics in ACL Reconstruction.  The failure rate is unacceptably high and if it is still used it should only be for select cases and for clinical studies


  1. No donor site morbidity
  2. Availability
  3. Rigid fixation possible , which allows early rapid rehabilitation


  1. High long term failure rate
  2. Higher infection rate
  3. Abrasion and impingement can lead to sterile effusions (swelling due to fluid in the knee)
  4. Poor results in 30% at 2 years (Australian Knee Society)
  5. Not permitted for intra-articular use in most European countries , because of unacceptably high failure rate
  6. Cost
Australian Knee Society Position Statement on Lars Ligament