Patellar Tendon vs. Hamstring vs. Cadaver Graft -

How am I to choose????

Since beginning this website in September of 1995, a frequent question asked concerns choice of graft materials to be used on an ACL surgical reconstruction. Frequently the writer and his (or her) doctor are planning an ACL reconstruction and discussed how a new ligament will be made. Either through  1) their doctor discussing other donor materials; 2) talking to friends; or 3) some research on his (or her) own; the writer realizes that this choice is not completely matter of fact.

Tunnels are drilled in the femur and tibia for graft passage (most methods regardless of graft type used)

Although research will find references to a huge number of donor graft materials, in the United States I would guess that about 95% (and that number is probably conservative) of first time ACL reconstructions are done with one of the three materials mentioned above. During the past 10 years, the central 1/3 (or lateral 1/3) of the patella tendon has been a very popular graft choice for surgeons to utilize. It is usually harvested with a piece of bone from the patella (knee cap) along with a piece of bone from the area that the patellar tendon inserts onto the tibia. This "bone-tendon-bone" donor material is then channeled up through the tibia bone across the knee joint and into the femur where it is held in place. The advantage of this reconstruction is that it is considered a very strong donor material and has a good shot of withstanding strong future stresses after proper rehabilitation. Criticism involves the potential problems that can accompany this repair including sensitivity of the patella and tibia where the bone was removed, increased recovery time, and potential complication of patella fracture.

Diagram Showing Donor Site of Central Patellar Tendon Graft

Patellar Tendon Graft

Hamstring repairs which used to be popular are receiving a resurgence in popularity in the past couple years. This graft involves harvesting tendons which come down the leg on the inner side of the knee, then once again channeling them through drill holes in the tibia, across the knee, and then fixed into the femur. This source of graft material had lost its popularity for some time due to perceived weakness compared to the patellar tendon repairs. However, newer techniques involving the way the graft is doubled or even quadrupled over itself and then fixed in different ways have its proponents showing biomechanical evidence of suitable strength. With the issue of suitable strength set aside, proponents feel that this repair technique offers advantages related to quicken rehab time since the patella and tendon have not been interfered with to obtain a graft material.

Hamstring Graft

An interesting anecdotal note. On February 16, 1997, during a meeting of the Arthroscopy Association of North America, a quick hand poll was taken of the approximately 1500 surgeons in attendance as to their preferred graft choice. This was not counted, but from my personal observation, I would say about 40% prefer hamstring repair and about 60% prefer patella bone-tendon-bone repairs. The implication clearly seemed to be that hamstring repairs are rapidly regaining popularity as a graft source. I feel that if the same poll would have been taken two years ago, that the results would have been more like 10% hamstring, 90% patellar tendon though once again, this is purely my own guess and opinion.

Allograft materials (cadaver) are frequently used in failed prior reconstructions and sometimes as the first choice in an ACL reconstruction. When used as a first choice, frequently the patient has a very specific need for the shortest possible recovery. More frequently, a prior reconstruction may have failed or there may be other specific reasons why the native surrounding donor tissue might not be available or suitable for the reconstruction. Although tested for infectious diseases by reputable tissue banks, surgeons and patients generally feel the safest knowing that their own native tissue is the source of donor graft material and don't have to then be concerned over even the most infinitesimal chance of disease transmission.

I hope you've found this page helpful.

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Last Updated 3/22/97