The decision regarding the proper graft is one of the most important decisions in ACL reconstruction surgery. The graft acts as a substitute for the damaged ACL and helps to restore knee stability, function and strength after injury.
One of the most frequently asked questions by patients prior to surgery is:
“Best graft for ACL reconstruction: Hamstring, quadriceps tendon, patellar tendon or something else?”
There is no one graft option that is best for every patient. Many factors such as age, body size, knee anatomy, ligament laxity, type and level of sport, muscle strength, previous surgery, lifestyle, and return to sport goals determine the best ACL Graft Choice in Dubai.
The goal is not just to choose the strongest graft but the best suited to the patient’s knee condition, daily activities and expectations for long-term recovery.
Hamstring Tendon Autograft
The hamstring tendon autograft is one of the most established and commonly used graft options for ACL reconstruction. It has a long clinical history and provides reliable outcomes for many patients.
In this technique, one or more of the patient’s own hamstring tendons are used to create the new ACL.
The main advantages include a smaller harvest incision, no removal of bone from the patella, and a lower risk of anterior knee pain and kneeling discomfort compared with a Bone–Patellar Tendon–Bone graft.
One consideration is the possibility of transient hamstring strength deficits, particularly knee-flexion strength during the recovery period, after harvest of the hamstring tendon. The impact depends on the patient’s activity level, sports requirements, and rehabilitation progress.
Quadriceps Tendon Autograft
The Quadriceps Tendon Autograft (QT graft) is another effective option for ACL reconstruction.
One of its important benefits is the ability to provide a strong graft with a substantial diameter and cross-sectional area, making it suitable for selected patients.
Who may be a good candidate for a Quadriceps Tendon graft?
The following factors may influence the decision toward a Quadriceps Tendon graft:
- Patients with generalized ligamentous laxity
- Patients with larger body size or knee anatomy where a larger graft may be beneficial
- Patients where hamstring tendons may not provide the required graft size
- Athletes where preserving hamstring function is important
- Selected revision ACL reconstruction cases
- Patients where another graft option is not suitable
In patients with generalized ligamentous laxity, the possibility of residual knee looseness or graft stretching may become an important factor while selecting the graft. In such cases, the Quadriceps Tendon can be a suitable option.
Similarly, in patients with larger knee anatomy, obtaining a graft with good thickness and strength may provide advantages. However, body size alone does not determine graft selection.
Some patients may experience a transient decrease in quadriceps strength during rehabilitation following QT harvest . With good physiotherapy and gradual strengthening, the muscle function can return.
Cost of Quadriceps Tendon ACL Reconstruction
Quadriceps Tendon ACL reconstruction involves different graft preparation methods and fixation techniques compared with conventional hamstring ACL reconstruction.
Quadriceps Tendon ACL reconstruction may be more expensive than the traditional Hamstring ACL reconstruction due to the need for specialized instruments and fixation devices.
Cost is one practical consideration in treatment planning. However, the choice of graft should also be based on medical considerations, the condition of the knee, lifestyle and expected outcomes of recovery.
Bone–Patellar Tendon–Bone (BPTB) Graft
The Bone–Patellar Tendon–Bone graft, also known as BPTB, is one of the classic and well-established graft options used in ACL reconstruction.
It has a long and successful history of use in particular amongst young high demand athletes. One of the great advantages is bone to bone healing which leads to solid graft fixation.
However, harvesting a BPTB graft requires removal of the middle part of the patellar tendon as well as bone blocks from the patella and tibia.
As a result, anterior knee pain, kneeling discomfort, and donor-site problems are important considerations.
This can be especially relevant for patients in the Middle East, where kneeling, sitting on the floor, or activities that place pressure on the front of the knee may be part of daily life.
Peroneus Longus Tendon Graft
The Peroneus Longus Tendon can also be used as an autograft option for ACL reconstruction.
Available studies have shown encouraging clinical outcomes with generally acceptable ankle function. However, more long-term studies are needed to better understand donor-site effects and the possible impact of tendon harvesting on foot and ankle function.
For this reason, the Peroneus Longus Tendon is not currently among the preferred routine graft choices for ACL reconstruction.
Rectus Femoris Graft: Different from a Quadriceps Tendon Graft
A Rectus Femoris graft is different from a Quadriceps Tendon graft, even though both donor areas are closely related.
A Quadriceps Tendon graft generally provides a thicker graft with a shorter available length. In selected techniques, the Rectus Femoris can provide a longer graft, which may be useful in complex reconstruction cases.
Potential applications include:
- Revision ligament reconstruction
- Multiligament knee reconstruction
- Complex cases requiring additional graft length
The harvesting technique, graft preparation, and reconstruction method also differ from a standard Quadriceps Tendon graft.
Rectus Femoris should therefore be considered a specialised graft option for selected complex cases rather than a routine choice for straightforward primary ACL reconstruction.
Allograft
An allograft is donor tissue used instead of harvesting a tendon from the patient’s own body.
One important advantage is that it avoids autograft donor-site problems. It can also be useful in complex procedures where multiple grafts are required.
However, particularly in young and active patients, some studies have reported a higher risk of graft failure or re-injury with allografts compared with autografts.
With modern tissue screening and processing methods, the risk of infection or disease transmission is very low, although it is not completely eliminated.
Allografts are usually more expensive and are generally restricted to specific situations such as:
- Complex revision ACL reconstruction
- Knee Multiligament Reconstruction
- Previous multiple ligament surgeries
- Procedures with multiple grafts
- Limited supply of appropriate autograft tissue
Does the choice of ACL graft depend on the type of sport?
Yes, sports activities can influence ACL graft selection, especially for professional and high-level athletes.
In sports such as football, basketball and handball there are repeated cuts, pivots, accelerations, decelerations and quick changes of direction. These movements put great stress on the reconstructed ACL and the surrounding muscles .
For athletes where sprinting ability, acceleration, and hamstring performance are important, preserving hamstring function may influence graft selection toward the Quadriceps Tendon.
On the other hand, sports requiring strong quadriceps function and knee extension should also consider the effect of QT harvest during early rehabilitation.
For a professional athlete, graft selection should not depend only on the sport. The playing position, level of competition, pattern of movement, the strength of the muscles, the anatomy of the knee and the risk of injury needs to be assessed.
For patients undergoing ACL reconstruction in Dubai, lifestyle, occupation, and daily activities can also influence the final graft decision.
Hamstring vs Quadriceps Graft: Which Is Better?
Both Hamstring Tendon and Quadriceps Tendon autografts can provide excellent outcomes after ACL reconstruction. Neither graft is universally better for every patient.
The Hamstring Tendon graft has a long clinical history, reliable results, and generally favourable donor-site recovery.
The Quadriceps Tendon graft can be a strong larger diameter graft and can be helpful for selected patients such as those with ligament laxity, larger graft needs, athletes needing hamstring preservation, and revision cases.
Their effects on muscle strength are also different. The harvesting of hamstring may affect the strength of knee-flexion and the harvesting of quadriceps tendon may temporarily affect the strength of knee-extension and quadriceps during early rehabilitation.
These differences are especially important when planning ACL surgery for athletes.
My Approach to ACL Graft Selection
Dr Farivar focuses on selecting the most suitable graft option based on each patient’s individual needs.
ACL reconstruction planning includes factors like knee anatomy, ligament laxity, activity level, sport requirements, previous injuries, and recovery goals.
The Hamstring Tendon remains a good option for many primary ACL reconstructions. However, if patient factors dictate otherwise, quadriceps tendon reconstruction may be more appropriate.
BPTB is a robust and scientifically accepted graft choice but donor site concerns such as anterior knee pain and kneeling discomfort are important variables to consider.
Similarly, the Peroneus Longus Tendon is not yet a routine grafting choice because of the need for more long-term data on donor site effects.
For complex revision ACL surgery or multiligament knee reconstruction, options such as Rectus Femoris grafts or Allografts may become part of the treatment strategy.
Ultimately, the right ACL Graft Choice in Dubai will depend upon the age of the patient, the anatomy of the knee, lifestyle and sports goals, previous surgery history and recovery expectations.
There is no single ACL graft that is perfect for everyone. The best graft is the one that fits the individual patient.
About the Surgeon
Dr. Farivar Bagheri is an Orthopedic and Knee Surgeon in Dubai specializing in ACL Reconstruction, Knee Arthroscopy, Sports Injuries and Personalized Treatment Planning.
He takes time to assess each patient to recommend the most suitable treatment approach to restore knee stability and help patients return to daily activities and sports.
FAQs About ACL Graft Choice in Dubai
1. Which graft is commonly used for ACL reconstruction?
Hamstring and Quadriceps Tendon autografts are among the most commonly used options for ACL reconstruction.
2. How is the right ACL graft selected?
The doctors consider the patient’s age, activity level, the anatomy of the knee, the demands of the sports, previous surgeries, and recovery goals.
3. Is Quadriceps Tendon graft stronger than Hamstring graft?
Both grafts can provide excellent results. The right choice depends on the patient’s individual condition and requirements.
4. How long does ACL graft recovery take?
The recovery period following ACL surgery varies with each patient, but the rehabilitation process generally takes several months to regain strength and stability in the knee.
5. Can every ACL tear be treated without surgery?
Not every ACL tear requires surgery. The decision depends on knee instability, activity level, injury severity, and the patient’s goals.