Wednesday 19 November 2014

Bone-Patella Tendon-Bone ACL Graft.

Which Graft should you consider for ACL reconstructive surgery?

This is an often debated question and the literature has many references to which is most appropriate for an individual.

The broad categories include

Autograft (Patients own tissue)
Allograft (Harvested tissue from a donor)
Synthetics (Manufactured material)

I will not drag open the debate but simply point each individual to the internet for interest and to discuss with their surgeon, the most appropriate graft for their reconstruction. Ultimately it is the patient’s choice.

My reasons and beliefs for my choice of graft are set out below.


I reserve this for revision surgery in my practice but will also offer autograft in revision should the patient prefer (sometimes using he opposite limb to harvest the graft). Allograft is expensive, has a slightly higher risk of failure in young people and possibly has a higher risk of infection. However there is no donor site morbidity (discomfort and some loss of function associated with autograft harvest from the patient).


This must be the graft of choice for first time ACL reconstruction. Typical grafts include, Bone-Patella tendon-Bone (BTB), Hamstring, and quadriceps tendon.

I choose BTB as my graft of choice as I have most experience with this graft. My harvest technique through small cuts and tunnelling out the graft allows a reduced level of discomfort on kneeling and ache at the front of the knee (a common complaint from patients who have a long midline incision to harvest the graft).
The fixation of BTB is very strong and if a patient is unlucky enough to suffer a rupture of the graft, there is good bone and not tendon within the placement tunnels making revision surgery easier.
Perhaps more importantly in professional footballers, there is now growing evidence of a reduced failure rate with BTB compared to Hamstring. This is perhaps the most compelling reason to use BTB over Hamstring.
It is important to understand that this is a personal choice and has worked well for my patients.


These can be used to augment an auto or allograft but rarely used at present as the main choice.

Will we ever know which is the most appropriate? In the UK now, a registry has recently been set up to record outcome after ACL reconstructive surgery. In time this should give us more evidence of the best graft choices in a set of circumstances and in any one particular surgeons hands. Visit for more details.


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