Every ACL reconstruction rests on one choice that patients rarely hear about: which tendon is used to build the new ligament. The graft decision is made before surgery, and it shapes the first months of recovery, the donor site and the long-term feel of the knee.

I am the author of a systematic review that compares the four main graft options. This article explains what each graft is, what the evidence compares and how the decision is made for an individual patient.

What the ACL does and why it is rebuilt

The anterior cruciate ligament controls forward movement and rotation of the shin on the thigh. A complete tear leaves the knee unstable in pivoting and cutting movements. The torn ligament does not heal back on its own, so reconstruction replaces it with a tendon graft that is fixed in tunnels in the bone. AAOS OrthoInfo explains ACL injuries and their treatment.

The four common autografts

  • Hamstring tendon: taken from behind the knee. A common choice with a smaller wound at the front of the knee and less kneeling pain.
  • Bone-patellar tendon-bone: the middle third of the patellar tendon with a bone plug at each end, giving bone-to-bone healing. It is often used in high-demand athletes.
  • Quadriceps tendon: a thick graft taken from above the kneecap, increasingly used.
  • Peroneus longus tendon: taken from the outer side of the lower leg, an option that avoids using tendons around the knee.

An autograft uses the patient’s own tissue. Each donor site has its own advantages and its own trade-offs.

A published comparison

My 2024 systematic review compares these four grafts for primary isolated ACL reconstruction. It was published in the Journal of Orthopedics, Traumatology and Rehabilitation (Vol 16, No 2, pp 183 to 190), and you can read it at DOI 10.4103/jotr.jotr_17_24. The review is the reason my graft discussions start from the published evidence and not from habit.

How the choice is made for one patient

The graft follows the person. The consultation weighs the sport and the level of play, age, the demands of work, the anatomy of the knee, kneeling needs, previous surgery on either leg and the patient’s own preference. A footballer who pivots, a runner, a padel player and a recreational gym patient can each end up with a different graft, and all of those choices are defensible when they are made on the findings and explained.

Surgery and the first months

ACL reconstruction is performed arthroscopically. I completed a fellowship in knee arthroscopy and adult joint reconstruction at Sancheti Institute in Pune in 2009. The new ligament is placed through tunnels in the bone and fixed, and meniscus or cartilage injuries found at the same time are treated in the same operation. Rehabilitation starts early with movement and swelling control, then moves through strength, control and running to sport-specific work. See knee arthroscopy and ACL reconstruction.

Return to sport follows criteria

The knee is cleared by testing, not by a date. Strength, hop tests, movement quality and confidence are measured, and the results decide when you return to pivoting sport. Returning to sport after an injury explains the process.

ACL injuries in Dubai

ACL tears come from football, basketball, skiing trips, padel, and sudden stops on the gym floor. Meniscus tears often come with them. A knee that gave way, swelled quickly or feels unstable deserves an examination. Book at Medcare JBR or Jumeirah.

Questions patients ask

Does everyone with an ACL tear need surgery?

No. Patients with low-demand activity and a stable knee sometimes do well with rehabilitation. Athletes who pivot usually need reconstruction.

Is a hamstring graft weaker?

The comparison of strength, donor-site problems and outcomes between grafts is the subject of the published review. The right graft depends on the patient.

Can I ask for a specific graft?

Yes. The consultation discusses your preference alongside the clinical findings.

What is a peroneus longus graft?

A tendon from the outer side of the lower leg, used as an autograft. It is one of the four options compared in the review.

Can I get a second opinion on a graft recommendation?

Yes. Bring the MRI and the report. More answers are on the FAQ page.

Check the facts yourself

Book an ACL consultation in Dubai

Call or WhatsApp +971 553117577, request an appointment online, or see the contact page for the address and consultation days. I examine the problem, review any scans you bring and explain each option before any decision is made.

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