There are different ACL graft options for you based on factors like your activity level and age. Knee Specialist Dr. J. Michael Bennett describes these graft options in this video, and he talks about the factors that might cause you to choose one ACL graft option over another. Dr. Bennett is a Board Certified Orthopedic Surgeon with a Certificate of Added Qualification in Sports Medicine. He’s also Fellowship-Trained in Sports Medicine.
For an evaluation of your knee injury, please call Dr. Bennett’s Sugar Land office at 281-633-8600 or his Houston Galleria office at 713-234-3152. You can also make an appointment online by using the Book an Appointment button at the top of the page.
– – Hello, my name is J. Michael Bennett, I’m an Orthopedic Sports Medicine Physician with the Fondren Orthopedic Group. Today we’re just going to briefly talk about ACL graft options and many of you out there, if you’ve had an anterior cruciate ligament or ACL injury, you’ve probably had this discussion with your doctor.
I just want to go over briefly what those ACL graft options are, and why we typically recommend certain grafts over others. These are my personal preferences, and your doctor may have his or her own ACL graft preferences. You should definitely discuss this in depth with your physician.
When you have a typical ACL injury, the first things we look at are your joint surface, your age, your activity status, and your expectations. Typically in my practice, the strongest ACL graft out there is the patellar tendon graft or Bone Tendon Bone graft (BTB graft).
This is the ACL graft that we used in my fellowship training with our elite athletes, with the football players, and with any high contact athlete. We also used the patellar tendon or BTB graft with younger patients who have closed growth plates, meaning that they’re probably older than about 15 or 16 years of age, but they’re younger than about 25 years of age.
The reason we call the patellar tendon graft a bone-tendon-bone graft is because we have a bone on one side, we have a tendon in the middle, and we have a bone on the other side. That graft is usually harvested from the patellar tendon.
The way that we harvest it is we make a midline incision in the front of the knee, and we dissect down to the kneecap. This is the quad tendon right here and this is your patellar tendon right down here. This is the patella itself. So this is patellar tendon, patella, and quadriceps — this is your whole extensor mechanism. This allows you to lift your leg up straight and up and down.
So what we do is we take out that central portion here, and a little plug of bone above and below. We take a little portion of your kneecap, and a little portion of the tibial tuberosity down here. Then we take the central third of the patellar tendon and that gives us a nice, robust graft.
There are two major benefits of this graft. Number one, it’s your own tissue. Number two, when we drill the holes as part of the ACL reconstruction, you’ve got your own bone growing to your bone so you get a better incorporation.
When we take this graft, we usually fill in these defects in the bone with bone graft that we use from a cadaver, and then we close up that defect. So you don’t have a defect in the middle of your patellar tendon.
This is a very good graft, it’s a very strong graft. The downside of the graft is, number one, it’s a little bit more painful because we’re taking bone plugs from both sides, and number two, you do have an incision in the front of the knee as we harvest this graft, However, if you’re going to be doing contact sports, if you’re an elite athlete, if you want the strongest graft out there, then this is definitely the gold standard.
A very close second is another ACL graft that we’re using more and more often now — the hamstring graft. The benefit of the hamstring graft, again, is the fact that it’s an autograft, meaning it’s your own tissue, so the incorporation is better when it’s your own tissue.
As a matter of fact there are some studies out there that do show that cadaver tissue in younger patients don’t do as well as autograft, meaning your own tissue in those certain patient populations. So, with the hamstring grafts, I use this as an option for patients in their 20s, all the way up to 45 or 50 years of age. It’s a good graft with good incorporation.
To harvest the hamstring graft, what we do is make a smaller incision down below the kneecap. We make an incision down here, and we harvest the distal thirds of two of the hamstring.
Now when you hear hamstring everybody thinks we’re going after the big, muscular muscle in the back of the leg. However we’re actually going after the tendinous portion down below the knee, over here. The muscle’s okay, we leave that alone, we don’t take any muscle away. We’re just taking the distal tendinous portion of it. The larges hamstring muscle in the back, which is the semimembranosus, we leave intact. It’s only the semitendinosus and the gracilis that we go after.
Once we take those two tendons, we loop them over a fixation device like this, and then you get a very thick, nice, robust ACL graft. You fixate it with a screw down on one side, and then a loop on the other side and that locks it into position and gives you good graft incorporation.
Now, I will tell you, some patients may have very small hamstrings so we may not be able to rely solely on the hamstring graft. So the third option, what I usually use in those patients, is something called the hybrid option. We use your hamstrings, and we augment it with a cadaver graft, just to give us a large enough diameter graft to give you a stronger construct.
This leads us to the fourth option, which is a straight cadaver graft. You have options within that realm between a soft tissue straight cadaver graft or a bone tendon bone straight cadaver graft, and that’s usually at the surgeon’s choice.
As far as cadaver ACL grafts are concerned, the benefit of that is that it’s not as painful because you’re not harvesting from yourself. However you’re getting the graft from a cadaver, so those grafts tend to take a little bit longer to incorporate.
I wouldn’t necessarily recommend cadaver grafts for really young patients, or at least, when their growth plates are closed. While their growth plates are still open, you can use a cadaver graft, but that’s more along the pediatric realm. I’d recommend you talk to a pediatric orthopedic surgeon about that.
For the patients we see at my practice, which is usually at least 15, 16 years of age all the way up, usually I’d recommend the autograft options over the cadaver graft options.
Please also check Dr. Bennett’s previous video on ACL Tears which also covers graft options.
For an orthopedic evaluation of your knee injury, please call our Sugar Land office at 281-633-8600 or our Houston Galleria office at 713-234-3152. You can also make an appointment online by using the Book an Appointment button at the top of the page.