AANA Lab Course 913 - Advanced Knee Course-ACL Graft Selection_ Evidence Based Recommendations Faculty Lecture

ACL Graft Selection_ Evidence Based Recommendations Faculty Lecture_ Kevin F. Bonner, MD

Pdf Summary

This presentation by Dr. Kevin F. Bonner reviews anterior cruciate ligament (ACL) graft options, indications, and considerations for graft selection in ACL reconstruction (ACLR). The major graft types are autografts—patellar tendon (PT), hamstring tendon (HT), and quadriceps tendon (QT)—and allografts.

<strong>Graft Selection Factors:</strong>  
Decisions depend on shared decision-making involving patient factors (age, activity level, sport, information sources) and surgeon factors (training, experience, graft preference). Graft choice varies worldwide, with hamstrings predominant globally, patellar tendon making a comeback, and quadriceps tendon gaining popularity.

<strong>Autografts:</strong>  
- <strong>Patellar Tendon (BPTB)</strong>: Offers bone-to-bone healing, reliable size/strength, less laxity, and lower revision rates in young pivoting athletes. However, it carries higher morbidity including kneeling pain (~10%) and risk of tendon rupture or fracture.  
- <strong>Hamstring Tendon (HT)</strong>: Variable size, multi-stranded with soft tissue fixation, higher failure rates in young athletes, but less donor site morbidity and kneeling pain. Graft size matters—larger diameters reduce revision risk.  
- <strong>Quadriceps Tendon (QT)</strong>: Emerging option with good size and strength, intermediate morbidity, but higher revision rates reported in registries (4.9% vs 1.6% PT) and concerns about cosmesis and complications.

Multiple meta-analyses show similar functional outcomes between PT and HT grafts, with BTB showing slightly better stability but more donor site morbidity. Revision rates tend to be lower for PT in young, high-risk athletes who prioritize reduced re-tear, while HT may be better for patients prioritizing less morbidity.

<strong>Allografts</strong> are popular (~22-43% US) due to no donor morbidity and faster surgery but generally show higher failure rates especially in younger active patients, likely due to slower biological incorporation.

Dr. Bonner’s indications:  
- PT for young, high-risk athletes who accept higher morbidity  
- HT for patients with growth remaining or kneeling demands  
- QT considered cautiously pending more data  
- Allografts mainly for older, less active patients seeking low morbidity

He emphasizes tailoring graft choice to patient age, activity, anatomy, risk tolerance, and goals, acknowledging “graft remorse” as real. Overall, PT and HT remain standard choices backed by strong evidence, QT and allografts selectively used.

In conclusion, ACL graft choice is a nuanced decision balancing re-rupture risk, morbidity, healing properties, and patient priorities for optimal individualized outcomes.

Keywords

anterior cruciate ligament

ACL reconstruction

graft selection

patellar tendon autograft

hamstring tendon autograft

quadriceps tendon autograft

allografts

graft morbidity

revision rates

shared decision-making