Sunday, January 10, 2021

Which ACL Graft is Less Likely To Tear Again?

Post op -view from the front
In all my years of being a physiotherapist, I have treated many patients and athletes who tore their anterior cruciate ligament (ACL) and opted to have surgery to repair it. 

View from the back
In the earlier days, the bone patella tendon bone (BTB) graft and the hamstring/ gracilis (HS) graft were the more popular choices. Allografts (cadaver graft) were not popular then, but they are definitely more accepted now.

I've had many patients (not just the athletes) who subsequently re-tore their HS graft. However, I have yet to encounter a patient who re-tore their BTB graft.

If my observations were accurate, surely then the BTB graft would be the 'better' and 'stronger' graft? Now it seems like there is evidence supporting my observations.

Researchers studied 770 patients (14-22 years) who were injured playing sports and had a six year follow up period. These patients had one normal un-injured knee and the injuredACL knee was reconstructed using the BTB or HS graft. Average age of the subjects was 17 years, of which 48% were female.

There were 492 (64%) BTB grafts and 278 (36%) HS grafts.

The chance of a subsequent  tear on the same reconstructed knee at six years was 9.2% compared to 11.2% in the uninjured normal knee. If it was either knee, the rate goes up to 19.7%.

The three most likely predictors of a subsequent re tearing of the operated knee were knee ligament laxity prior to knee operation, graft selection and age.

Those patients who had a HS graft were 2.1 times more likely to re-tear their ACL graft compared to those who had the BTB graft.

Choosing your graft after tearing your ACL will definitely be influenced by discussions with your doctor, surgeon and physiotherapist etc. Moreover, besides the BTB and HS grafts, you can also use an allograft (cadaver) now. 

Please bear this information in mind if you were to tear your ACL. Please come talk to us if you have any questions.


Spindler KP, Huston LJ, Zajichek A et al (2020). Anterior Cruciate Ligament Reconstruction In High School And College-age Athletes: Does Autograft Choice Influence Anterior Cruciate Ligament Revision Rates? 48(2): 298-309. DOI: 10.1177/0363546519892991.

R knee

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