Graft selection in anterior cruciate ligament reconstruction

The ideal graft for use in anterior cruciate ligament reconstruction should have structural and biomechanical properties similar to those of the native ligament, permit secure fixation and rapid biologic incorporation, and limit donor site morbidity. Many options have been clinically successful, but the ideal graft remains controversial. Graft choice depends on surgeon experience and preference, tissue availability, patient activity level, comorbidities, prior surgery, and patient preference. Patellar tendon autograft, the most widely used graft source, appears to be associated with an increased incidence of anterior knee pain compared with hamstring autograft. Use of hamstring autograft is increasing. Quadriceps tendon autograft is less popular but has shown excellent clinical results with low morbidity. Improved sterilization techniques have led to increased safety and availability of allograft, although allografts have a slower rate of incorporation than do most types of autograft. No graft has clearly been shown to provide a faster return to play. However, in general, patellar tendon autografts are preferable for high-performance athletes, and hamstring autografts and allografts have some relative advantages for lower-demand individuals. No current indications exist for synthetic ligaments.