A quick primer on what ACL surgery is: Once the ACL is torn it does not repair itself. Thus, a graft is used to form a new ligament. This graft is put in place where the ACL should be.
If you decide to have ACL surgery, one of the next steps is to decide which graft to use. There are a quite a few options:
- Patellar graft (click for video) –This is where part of the patellar tendon is cut off and then put back together.
- Hamstring graft –Part of the medial hamstring is used.
- Cadaver graft (allograft) –Part of a dead person’s tendon is used. It’s not guaranteed which tendon you will get. You might get an achilles tendon, patellar, anterior tibialis, etc.
- Achilles tendon
- Iliotibial band (IT Band)
The last two, an achilles and IT band graft, are very rare in the reconstructive ACL scene. They are no where near as well studied as the patellar, hamstring and allografts. I consider entertaining the achilles or IT band grafts as entertaining the idea of being a science experiment. Because I have no desire to be a guinea pig, I’m not going to discuss these options any further. The patellar, hamstring and allografts will be looked at in depth.
Much like trying to decide whether surgery is a viable option, the research on this area is all over the place. A lot of the studies are crappy retrospective studies, and there aren’t many good, randomized controlled studies. Again, I won’t completely discount the retrospective studies, but I won’t hang my hat on them either.
–
Autograft versus allograft (a graft from your own body versus a cadaver graft)
The biggest proposed perk of a cadaver graft is you don’t have to recover from the ACL surgery AND another surgical incision. A patellar or hamstring graft from your own body involves cutting open other parts of your body. This is another injury you now have to recover from. However, this doesn’t automatically mean you should use an allograft. Issues arise with them as well.
There are a couple of very good, and recent, randomized studies comparing patellar tendon autografts versus allografts, and hamstring autografts versus allografts. The studies compared aspects like failure rate, stability, activity score, vertical jump, etc.
The autografts consistently come back with better results, but they are very small differences. Differences not worth worrying about.
One thing worth worrying about is the risk of infection between the two grafts. With allografts you really never know for sure what you are getting. The tissue is from another dead person’s body, running the risk of carrying disease. Again, the differences are small, 1.3%, but the autografts group had a ZERO chance of infection. (The cadaver groups had a 1.3% risk.)
Infection can severely hinder the rehab process. Not to mention there’s the (small) chance of amputating your leg, or death. You already have a risk of infection from being in a hospital and having surgery; using an allograft increases that risk.
You aren’t guaranteed to get a patellar or hamstring allograft either. Many times an achilles or anterior tibialis tendon are used. These grafts don’t have as high of a success rate as patellar and hamstring grafts. I haven’t looked into it, but I’m not really sure if you can request the type of allograft you get. Because your name has to be added to a donor list I’m assuming the answer is no. You are likely stuck with whatever is available.
Next, you don’t know the age of the person who is providing the graft. More and more research is coming out suggesting the age of the graft is very important regarding graft failure i.e. older people’s grafts fail more often. I highly doubt you are able to request a “25 year old, male, fully disease free, patellar or hamstring graft.” I could be wrong though.
Keeping with age, a few studies have recently found that, when stratified for age, the rate of graft failure goes way up in younger populations using allografts. Now these studies used things like an achilles graft or an anterior tibialis tendon, which are not ideal, but they are some of the very few that have controlled for age when looking at graft failure rates.
The numbers in these studies are alarming. Failure rates of 25-50% were found in young populations. I really think there is something else going on with these studies -the failure rates are just too high and too different than other studies- regardless, you aren’t going to find this high of a failure rate in autografts, ever. The surgeons I talked to all cited my age as one reason to NOT go with a cadaver graft.
Allografts just have a lot more potential complications. There are even crazy ass stories of donation places lying about the tissue they are giving in order to up sales.
There is only one positive to them: Allografts definitely do have the positive of lessening the damage to the body. Because the autografts involve cutting tissue from other areas of the body there are risks of losing strength at those sites. For example, patellar tendon patients are notorious for having trouble regaining quadriceps strength and knee extension. (This makes sense since a third of their tendon is gone!) It is also common for these patients to have long-term knee pain. For hamstring patients, there is some evidence they have issues regaining knee flexion strength.
Proponents of allografts will say this enables allograft patients to return to their sport quicker. Maybe an allograft will allow you to return to walking quicker. In regards to getting back to high level sports though, it’s just not true.
Since allografts are from another person’s body they can take longer to remodel into a ligament compared to autografts. Your body is going to have an easier time with its own tissue than someone else’s.
Also, the injuries from an autograft take around 8-10 weeks to heal. The first 8-10 weeks of physical therapy aren’t heavy strength or range of motion wise to begin with. (You don’t want to stretch the graft out.) Some people aren’t even walking til a couple weeks after surgery. Thus, you’re not losing much by not being able to strengthen those areas yet.
Lastly, look at the people who have the most incentive to return to sports quickly. People where every week matters: professional athletes. Autografts are way more common in this population. If allografts returned people that much faster, those with millions of dollars on the line would use them.
The projected return to sports in an accelerated patellar graft patient is 4 to 5 months. NOBODY with an allograft is returning faster than that. NO.BUD.EE.
I just don’t see much of an argument to get an allograft. If you’re older, like 50, and you don’t care about returning to a high level of activity, then maybe. But if that’s the case, do you even need the surgery to begin with?
–
Patellar versus hamstring graft
Which of the autografts should we choose though?
This is actually very similar to examining allografts versus autografts. In terms of the big outcomes like return to activity, stability scores, failure rate, etc. there is minimal differences between the two grafts. Much like allografts and autografts, differences not worth worrying about.
The difference that ends up being pronounced is the potential for complications: Patellar grafts have a greater chance of issues:
- ACL patients are notorious for having issues with quadriceps strength and regaining full knee extension range of motion. Regardless of the graft used. Taking off a chunk of the patella further adds to the likelihood of these issues.
- Patellar patients consistently report a greater amount of knee pain post-op. Whether it’s 6 months out or 6 years. Especially when it comes to kneeling and deep squatting.
- Patellar patients run a greater chance of arthritis down the road due to the aforementioned reasons.
- The risk is very small, but there is a risk of fracturing the patella when obtaining the graft due to power drilling the patella.
Hamstring grafts don’t run the above potential issues.
There are some studies that find patients have trouble recovering hamstring strength, but there are also studies that don’t find this. Probably indicative of how good a rehab the patient had. Also, it makes sense hamstring patients will have an easier time recovering knee flexion strength than patellar patients will have recovering knee extension strength. The hamstring will regrow, like a lizard’s tail; this appears much more iffy with the patellar tendon. (If it happens, it can take longer than the hamstring.) Either way, it’s not consistent enough of a finding for me to worry about it.
–
The meniscus
A meniscus tear accompanies an ACL tear in around 75% of all ACL tears. If the meniscus is repaired, knee flexion strengthening and range of motion is limited the first 8-10 weeks of therapy. When else is knee flexion strengthening and range of motion limited the first 8-10 weeks? In a hamstring graft patient.
If you are having your meniscus repaired it makes sense to choose a graft that most accompanies your therapy. If you had your meniscus repaired, but chose a patellar graft, you are not only running the risk of limited knee flexion, but having issues with knee extension as well. Rather than have potential issues with my quads and hamstrings, I’d prefer to be able to at least strengthen one area of my leg.
Of course, not all meniscus tears are repaired and not all ACL tears have a concomitant meniscus tear. So this may not factor in.
Adding to the case for a hamstring graft, all the surgeons I’ve talked to prefer the hamstring graft.
The only area I see patellar grafts win out is an earlier return to high level sports. I’m not sure if this true for healing reasons or because patellar grafts have been more common in the past (maybe the therapy is a little more understood, thus, better).
Some people propose the patellar graft heals quicker than hamstring grafts because patellar grafts are attached bone to bone where as hamstring grafts are attached tendon to bone. Some believe bone attached to bone heals quicker than tendon to bone. It’s logical, but unproven. This also assumes no associated meniscus issues. Not typically the case in an ACL tear. Note that if you have a meniscus tear your recovery is going to be longer regardless. Negating the possible quicker return by the patellar graft.
Keep in mind we’re only talking about, maybe, a month difference between the grafts. I’m not worried about whether I play dodgeball in 6 months or 7 months. That’s for people who get paid to play sports. I’m worried about playing sports 10 years from now.
Others will say the patellar graft has greater stability outcomes. It often does. But the patellar graft also runs the risk of losing knee extension…If you have a less mobile knee no wonder it’s more stable…Furthermore, there’s no research to suggest this slightly better stability outcome improves functional outcomes: Both graft patients return to the same level of activity.
-> The one exception here is very high level sports. By definition, 99% of us are not worried about this, but patellar grafts have some advantages.
–
Summing up
Since that was quite a bit of text I threw together a simple chart marking which graft is better for which outcome:
|
Outcome |
Patellar |
Hamstring |
|||
|
Stability |
P |
|
|||
|
Return to high level of activity |
Tie |
Tie |
|||
|
|
|||||
|
Pain |
H |
||||
|
Arthritis |
H |
||||
|
|
|||||
|
Range of motion |
H |
||||
|
|
|||||
|
Associated meniscus repair |
H |
||||
|
|
|||||
|
Speed of recovery |
P |
||||
|
|
|||||
|
Complications |
H |
||||
|
|
|||||
|
Recovery of strength |
H |
||||
With that said, the overall difference between the grafts are minimal. While all the surgeons I talked to prefer a hamstring graft, it’s not as if they were against the patellar. (From the surgeries I’ve seen, a hamstring graft is easier to harvest.)
One of the biggest factors when deciding which graft might be your preexisting history. If you already have a history of knee pain do you want to choose the graft (patellar) that has the greatest chance of increasing that knee pain? No.
Also of great importance is your surgeon’s preference. If you feel really comfortable with a surgeon, something that is hard to come by, I’d probably just defer to their preference. (As long as you are deciding between a patellar and hamstring!) Knowing someone is going to do a good job likely outweighs the small differences between the grafts. If the guy cutting my leg open prefers the graft that doesn’t involve possibly fracturing my patella, I’m going to go with that.
I’ll end this with saying you need to look at the last ten years on this subject. Up until maybe around 2004, patellar grafts were considered the gold standard. They seemed to have better outcomes, and were way more common. Since there have been changes to the hamstring graft, where the superiority of patellar grafts doesn’t appear to hold true any more. There appears to be a movement towards preferring hamstring grafts.
–
Some references
Note this is hardly complete, but I’ve nearly gone blind trying to read all this crap.
I tried to post either some of the most important studies or the best ones. One can easily cherry pick studies to make their argument; hopefully I am not doing that.
Remember, when it comes to areas that have a great amount of research behind them there is always one study contradicting another study. Without reading every single study it’s very hard to know what is more prominent, which is often what’s most important. Remember my thoughts above are mostly related to either the few randomized studies, and or, the most apparent trends in the research.
Lastly, remember the date of the research is important when it comes to patellar grafts versus hamstring grafts. We’re most concerned with the most recent research.
-Allograft versus autograft
Age of donor is important:
http://www.ncbi.nlm.nih.gov/pubmed/18716694
Higher failure rate in younger athletes:
http://www.aaos.org/news/aaosnow/sep08/cover3.asp
http://www.ncbi.nlm.nih.gov/pubmed/17478276
Higher risk of infection; minimal differences elsewhere
http://www.ncbi.nlm.nih.gov/pubmed/19560639
http://www.ncbi.nlm.nih.gov/pubmed/21441418
–
-Patellar versus hamstring
Greater knee pain and or chances of arthritis in patellar group; minimal differences elsewhere:
http://www.ncbi.nlm.nih.gov/pubmed/15572332
http://www.ncbi.nlm.nih.gov/pubmed/20953764
No differences
http://www.sciencedirect.com/science/article/pii/S096801600100062X
Potentially quicker recovery in patellar group, length of recovery with meniscus repair:
Recent advances in the rehabilitation of anterior cruciate ligament
fiddle b.
February 15, 2013
I found this study on using the tibialis anterior as an acl graft. Looks like it’s gaining in popularity due to it’s strength. I looked it up because my surgeon will be using it on me:
[redacted broken link]
reddyb
February 17, 2013
The strength of the graft in vitro isn’t too significant. From what I remember, it’s either all or nearly all of the grafts are stronger than a regular ACL.
Over time as the graft remodels into an ACL it will actually become weaker than it originally was e.g. in vitro. So, basing your decision off this one metric is futile.
Sorry, but that study does nothing to to make a case for using the tibialis anterior. Using the tibialis anterior puts you in a guinea pig (experiment) category.
And I would love to know why that study is coming out of the “Department of Dentistry.”
Rudy Loyero
January 18, 2014
Hi Brian,
First of all I would like to thank you for all the help you have been so far as I read all of your material regarding ACL surgery.
I am a 31 year old male who lives in New Jersey and tore my ACL completely, partially tore my MCL and no meniscus damage (Thank God!!) on my left knee playing soccer on Thanksgiving morning (11/28/13). I am a huge sports fan and love playing soccer, tennis, basketball, jogging, etc. I do not play professionally, just as a hobby and to keep me in form.
I can’t even begin to explain to you what I have been through so far (I am scheduled to have surgery on 01/30/14). I was scheduled for surgery on 01/07/14 with a surgeon that I was not too happy about, he gave me a knee brace that immobilized my knee and told me to not move my leg too much so the MCL can heal quicker. As dumb (and desperate?) I was feeling and did what he told me, and starting to feel pain in my left calf. I went to see him 2 weeks later as he gave me that appointment and told him about my pain and sent me to do an ultrasound and said my leg was too stiff and need to go to therapy (12/27/13 one month after my injury) They found a blood clot DVT (Deep Vein Thrombosis) below the knee and prescribed Xarelto for this treatment.
I spoke to my primary physician, explained to him what was going on and he told me to not take the Xarelto, and go with an aspirin 325mg. Not to mention that when I went to see the surgeon he made me wait for 1 hour, and when I walked to the bathroom I saw he was with another patient in another room. I was so pissed off and made me believe this guy doesn’t care or maybe I needed somebody who would give me more personal treatment and be on top of everything for me.
I also spoke to a friend of mine who lives in Spain and tore his ACL as well and he gave me some advice regarding everything that I was going through. He decided to have surgery with a autograft hamstring draft.
So I decided to go for a 2nd opinion, my therapist recommended a orthopedic surgeon and setup an appointment with him. I feel comfortable with him, I explained my whole situation and he wasn’t happy with the way I was handling it with my previous surgeon.
He told me that 70% of his patients choose an allograft and he recommended me that treatment, he gave me his explanation on it but he told me to do my research and that if I feel comfortable with an autograft that he will not have a problem with it. He wants me to decide which is the best option for me. He also told me to keep going to therapy and come surgery date, be able to flex my knee 120 degrees (so far I can bend it 110 degrees thanks to therapy, and I can completely straighten it).
As you can tell I am overwhelmed with all of this that I went through and I would like your personal opinion on this as I have decided who I will have surgery with, the date, but I am still a little shaky on deciding if I should go with an autograft or allograft. I’m leaning towards an autograft (hamstring) but want to be 100% sure.
I greatly appreciate you taking the time to reply. Looking forward to your posts and response.
Thanks
Rudy
reddyb
January 20, 2014
Hey Rudy,
Sorry to hear about your troubles. You’ve learned the hard way how immobilizing an injury can often be a bad idea.
Regarding advice, I’m not sure what else you’re looking for from me. My view points on grafts are fully encapsulated in this post.
If you have a more specific question I could perhaps give you something, but if your question is simply, “What graft do you like?” That’s all covered in the post.
Regarding other aspects of your post, you said “I can’t even begin to explain to you what I’ve been through so far.”
This quote worries me, a lot. To be blunt, you have not entered the worst phase of this process. The worst phase begins January 30th. You should be very, very well prepared for this fact. I’d read the comments in this post to get an idea of what lies in front of you: http://b-reddy.org/2012/01/06/reconstructive-acl-and-meniscus-repair-surgery-physical-therapy-days-2-11/#comments
Lack of preparation is the biggest mistake ACL patients make: http://b-reddy.org/2013/10/23/the-biggest-mistakes-acl-patients-make/
Rudy Loyero
January 22, 2014
Hey Brian,
Thanks again for your reply, I have read these links and have gotten an idea of what you are talking about,
I really appreciate your time and hopefully the surgery goes well.
At the moment, I am doing a lot of therapy before the 30th to be in best shape possible.
I will keep in touch if anything comes up, but I think I am leaning towards a hamstring autograft.
Thanks again
Rudy
reddyb
January 22, 2014
You got it. Seems like a smart move.
Best of luck.
Fidel
January 23, 2014
I had a hamstring autograft (doc chose for me) and kind of regret it. Almost one year later and my hamstring is really weak. They take 1 or 2 tendons from the hamstring and I need those to run! I can run now but can’t sprint or do long distance. I would’ve chosen cadaver because I also don’t want my patella tendon compromised. Good luck.
reddyb
January 24, 2014
First, to be clear, a hamstring graft does not constitute one or two tendons being taken. Part of those tendons are taken, and they can regenerate. Regenerate to the point they are full again? Probably not. Regenerate to the point you get nearly full (~90%) strength back? Yes.
Keep in mind the purpose of a hamstring graft is to first have a healthy knee, then a return to more dynamic activity. In a patellar graft, the priority is first a return to dynamic activity, then a healthy knee. This is why high level athletes go with the patellar. The health of their knee when they’re older isn’t their first concern.
For anyone who isn’t a professional athlete, 99.99999% of us, the health of the knee, not it’s sprinting performance, is the first priority. Because when you’re older chances are you won’t care about sprinting anyways.
Considering the average career of most professional athletes is less than 5 years, I could make an argument the health of their knee should be their first concern too. Better to prepare for the rest of your life after your 25 years old then only your life up to 25 years old.
Please be careful about anecdotal suggestions. A cadaver graft is the last graft you want if athletic performance is a concern for you and or you’re relatively young. I go over this in the post -such as their high failure rates, and you can examine professional athletes again here: None of them get cadavers. I can very easily make the case if someone is considering a cadaver they’re better off not getting the surgery at all.
It might not be the hamstring graft which has presented you an issue, it may have been your therapist / therapy since surgery. More than likely, it was and has been inadequate. This is not based off what I know about you, which is nothing, it’s based off what I know about the physical therapy profession.
Finally, it takes 18 months to really know how things have gone for a person. At less than a year, you have a ways to go.
Fidel
January 25, 2014
Good info, Brian. But, a little about me so you can see where I’m coming from. I used to be a professional athlete. I played professional baseball for 7 seasons. In 2010, I was ranked top 50 in the 100 and 200. Top 25 in the 400 in ’08. You can look it up here: mastersrankings.com. I had high hopes for a good 2013 season based on my indoor 60m times until the injury. My point is that you don’t have to be a professional athlete to still have that mentality.
Also, elite sprinter English Gardner had a cadaver graft for her acl reconstruction. So, some do get cadavers. You can ask her on twitter.
And, you’re probably right in that it’s still early in my rehab but I still question my doc’s decision to use hamstring when my biceps femoris detached during the injury. No medial and lateral hamstrings really make it difficult to stabilize and rehab the knee.
Even though it’s taking forever, the good thing is that I still see improvement each week. But, I’d be so far ahead if I still had my hamstring tendons.
Forgot to mention that I asked my doc directly if parts of the semitendinosus and gracilis are taken and he said no. The tendons are gone. Youtube videos clearly show they get cut…not stripped. He did say that in Europe, surgeons are using regenerated hammy tendons for acl reconstructions. Kinda balsy of them.
reddyb
January 26, 2014
I understand where you’re coming from. My contention is having the professional athlete mentality when you aren’t a professional athlete is counterproductive. It leads to things like improper training and injuries.
I’m not arguing some get cadavers, I’m arguing the research says, based on demographic, on average, most who tear their ACL are better off not getting cadaver grafts. It’s like saying, “Some people smoke their whole lives and still live to be 80.” Great for that person, but doctors still shouldn’t be advising people to start smoking.
Let’s compare Gardner to Adrian Peterson, who had a patellar graft. Peterson comes back and is at the top of his sport about 9 months after his surgery. From quick research on my part (I don’t know Gardner’s history well) it took Gardner 15 months or so. For a world class athlete, that’s a slow recovery.
“Adrian Peterson is one example!””
So is English Gardner.
Both, however, are extremely high level athletes. Average Joes should not be using them as examples of optimal treatment.
Even if you did, based off her recovery, you’d have a hard time saying you’d be so much further ahead as she wasn’t that far at the less than a year mark.
Gardner is an unusual example too. Track athletes don’t need their ACL like others do. Others like basketball, football, those who cut back and forth a lot. She tore her ACL playing flag football, but got a new one for track. Most people get a new ACL for the sport they tore it in.
A track athlete could very well be better off taking their chances with a cadaver and leaving their tendons alone. But, we shouldn’t be using this as the precedent for how we treat ACL patients. Most ACL patients don’t tear their ligament running in a straight line.
In terms of treating the track athlete: The slight decrease in tendon strength may very well not be worth the much better graft. For a football player, the slight decrease in tendon strength is very much worth the better graft. It’s not impossible to play football with slightly weaker tendons, it’s pretty much impossible to play with a shitty ACL. English Gardner can get away with not having as good of a graft; Adrian Peterson can’t.
Look at Robert Griffin as another example. The first time he tore his ACL he had a patellar graft. The second time he tore the same knee and what graft did he have? A patellar graft from the opposite knee! He has what most consider the top surgeon in the world working on him (James Andrews). The top surgeon in the world feels that strongly in favor of autografts versus allografts.
I didn’t do a good job of clarifying what I meant on this. To say it another way, enough of something like the semitendinosus is left so that the tendon can regenerate. It is not as if the tendons are completely gone and never coming back. There’s plenty of research looking at regeneration in hamstring grafts.
What I want to make sure of is I don’t want people thinking a hamstring graft = their hamstrings will never work again. I’m nervous you saying, “My tendons are gone” is giving that impression.
Alex
November 1, 2020
Hi Brian,
What are your thoughts on the use of a quadriceps tendon autograft?
b-reddy
November 3, 2020
Hey Alex,
Not something I’ve looked into. In general, and certainly with ACL procedures, anything “new age” or “cutting edge” is something I’m extremely wary of. Primarily based on the lack of track record / likely inexperience the surgeon / physical therapist will have with it.