Injuries to the Anterior Cruciate Ligament (ACL) are common among athletes and active individuals. Surgery is often required when the ACL is torn to restore knee stability and function. However, ACL reconstruction (ACLR) comes in multiple types depending on the source and kind of tissue used, and the surgical technique, each with its pros and cons.

In this post, we will discuss the main types of ACL surgery, compare their advantages and limitations, and suggest the parameters that need to be considered before undergoing the surgery.

What is ACL Reconstruction?

When the native ACL is torn, simply removing it does not restore knee stability. The standard solution is to replace it with a “graft”, a tendon (or portion thereof) that acts as the new ligament. In surgery, tunnels are drilled in the femur and tibia bones, the graft is passed through and fixed in place to replicate the function of the original ACL.

Graft choice is among the most important modifiable factors influencing outcomes such as graft rupture or need for revision. Graft options broadly divide into:

Autografts: tendon tissue harvested from the patient’s own body Allografts: donor (cadaver) tissue.

Within autografts, the most commonly used tendons are from the patellar tendon, hamstring tendon, or quadriceps tendon.

Main Types of ACL Surgery/Grafts: Pros and Cons

Here’s a breakdown of the main graft types used in ACL reconstruction and their advantages and limitations:

Patellar Tendon Autograft (Bone-Patellar Tendon-Bone, BPTB)

What it involves:

The surgeon harvests the middle one-third of the patient’s patellar tendon (which lies just below the kneecap), along with small bone plugs from the patella and tibia, hence “bone-tendon-bone.”

Pros:

Bone-to-bone healing occurs relatively quickly, giving a strong, stable fixation. Historically regarded as the “gold standard,” especially for young athletes or those involved in high-impact or contact sports. Among autografts, it tends to have one of the lowest graft-failure/re-rupture rates.

Cons / Trade-offs:

The patients may experience anterior knee pain, difficulty kneeling, and possible patellofemoral pain in the long term. The incision is more invasive (to harvest bone plugs), and recovery of the extensor mechanism (quadriceps / patellar mechanism) may take longer or be more painful.

Best for: Young, active individuals, especially athletes participating in sports with jumping, pivoting or contact, where maximum stability and low re-tear risk are priorities.

Hamstring Tendon Autograft (HT)

What it involves:

Tendon tissue is taken from the hamstring (back of the thigh), typically semitendinosus and sometimes gracilis, folded or bundled to form a graft, and fixed in the drilled bone tunnels.

Pros:

Harvest involves smaller incisions and less trauma compared to BPTB, resulting in less initial donor-site pain and less risk of issues like kneecap pain. Patients often report better comfort when kneeling and less anterior knee pain. A good option for individuals who may not need the absolute bone-to-bone healing strength of BPTB grafts.

Cons / Trade-offs:

Healing is tendon-to-bone rather than bone-to-bone, which may take longer. According to some studies, it has a somewhat higher risk of graft failure compared to BPTB. There could be some reduction in hamstring strength after surgery, and slower return of full muscle function. Initial graft fixation may be less rigid compared to BPTB, possibly influencing early stability and rehab timelines.

Best for:

Adult patients, moderately active individuals, or those for whom donor-site morbidity (pain, kneeling discomfort) is a concern. Also, it is a reasonable option when preserving knee extensor mechanism is preferred.

Quadriceps Tendon Autograft (QT)

What it involves:

A portion of the quadriceps tendon (just above the patella) is harvested and used as the graft. This can be done with or without a bone plug depending on the technique.

Pros:

Provides a thick, strong graft, often comparable biomechanically to BPTB. Lower risk of patellar tendon donor-site complications (since patellar tendon is untouched). Useful especially in revision ACL surgeries or where previous graft harvest has exhausted other tendon sources, because QT often gives sufficient graft material and strength.

Cons / Trade-offs:

Some decrease in quadriceps strength post-operatively, especially early on. Rehabilitation may be slower compared to HT.

Best for: Patients who need a strong graft but want to avoid patellar tendon morbidity; Patients with prior graft harvests, revision ACLR Patients whose anatomy or tendon availability makes hamstring grafts suboptimal.

Allograft (Donor / Cadaver Tissue)

What it involves:

Instead of harvesting from the patient, a tendon (e.g., patellar tendon, hamstring, Achilles, etc.) from a donor (cadaver) is used.

Pros:

No donor-site morbidity for the patient, no tendon removal from own body, thus no additional surgical wound other than the reconstruction incisions. Shorter surgery time, less post-operative pain. Preferred for older patients or those for whom multiple surgeries/ previous surgeries make autograft harvest difficult.

Cons / Trade-offs:

Allografts incorporate more slowly (slower graft “maturing” / integration) compared to autografts. Higher risk of graft failure / re-tear, especially in younger, active, or athletic individuals. Potential (though very low) risk of disease transmission (depending on graft processing / screening practices).

Best for: Older patients, or those with comorbidities / prior surgeries where autograft harvest is not ideal. But generally not preferred for young, active or competitive athletes.

Emerging / Less Common Techniques & Considerations

In addition to traditional graft-based reconstruction, newer or alternative approaches are gaining interest:

“All-Inside” ACL Reconstruction It uses shorter bone sockets (rather than full bone tunnels), minimizing bone removal and possibly reducing post-operative pain/bone loss.

Hybrid Grafts It combines autograft hamstring tendon with a small amount of donor (allograft) tissue, particularly when harvested hamstring graft diameter is small, to achieve better graft strength.

Revision ACL Reconstruction Strategy For revision cases (recurrent tear), thicker grafts from BPTB or QT seem to have a lower tendency for graft failure than HT.

These alternatives illustrate that graft choice and surgical technique are not one-size-fits-all. The decision must be personalized, considering multiple factors, including, patient’s age, activity level, prior surgeries, and expectations.

What Every Patient Should Know When Consulting Their Surgeon

There is no “one best graft” universally. Optimal graft depends on your age, activity level, knee anatomy, donor-site morbidity tolerance, previous surgeries, and long-term goals.

Autografts (your own tissue) generally give better long-term stability, lower re-tear risk, and more reliable graft incorporation than donor tissue (allograft), especially in young/active patients.

Among autografts:

Patellar tendon (BPTB). Strongest fixation, rapid bone-to-bone healing, but risk of knee pain or kneecap issues.

Hamstring tendon Less morbidity, more comfort post-surgery, but slightly higher failure risk and slower graft healing.

Quadriceps tendon Promising alternative, especially for revision surgery or when other graft sources are not ideal.

Rehabilitation, compliance, and gradual return to activity are as important as surgical technique. Graft choice only sets the stage, successful recovery depends on post-operative care.

Conclusion:

Although most doctors recommend ACL reconstruction, most likely Patellar tendon (BPTB), for maximum strength, bone-to-bone healing and lowest long-term risk of re-tear. However, if the patient prioritizes long-term knee comfort, kneeling, reduced post-operative pain, or has lifestyle considerations (e.g. yoga, floor-based work, knee-heavy daily life), you can consider Hamstring tendon autograft and discuss benefits vs slightly higher re-tear risk with your surgeon. For revision cases or situations where previous grafts have been used, Quadriceps tendon autograft may be a very good choice, says Dr Manu Bora.

Ultimately, the “best” ACL surgery is the one aligned with your lifestyle, anatomy, and long-term knee health, not merely the “strongest” graft, says Dr Manu Bora. He recommends a thorough pre-operative discussion with your doctor and personalized decision-making before making a decision .