ACL Graft Choice

Graft 01

Hamstring tendon (4-strand semitendinosus)

My standard primary graft

The most widely used graft in the UK. My technique is a four-strand semitendinosus: a single hamstring tendon, folded into four strands and fixed with adjustable-loop suspensory fixation at both ends (“double suspensory”). Folding one tendon into four reliably produces a thick graft — diameter matters, because grafts under 8 mm fail more often — while sparing the gracilis tendon and preserving hamstring strength.

The older method used two strands each of semitendinosus and gracilis. It served a generation well, but taking gracilis too measurably weakens deep knee flexion — strength that matters to sprinters, martial artists and anyone who squats and kneels for a living. Where the semitendinosus alone is big enough, the second tendon is unnecessary.

Graft 02

Bone–patellar tendon–bone (BTB)

Best for: young pivoting athletes

The middle third of the patellar tendon with a block of bone at each end. Bone heals to bone inside the tunnels — the most secure biological fixation — and in young athletes returning to cutting and pivoting sport the registry evidence consistently shows the lowest re-rupture rate of any graft. For the young footballer or rugby player whose one priority is “never again”, BTB is still hard to beat.

Graft 03

Quadriceps tendon

Best for: strength with less donor pain

A strip of the quadriceps tendon above the kneecap — a thick, robust graft with a larger cross-section than the patellar tendon, taken through a small incision. Once niche, it has become a premium first-line choice: recent studies show stability and failure rates comparable to BTB with less donor-site and kneeling pain. Excellent for young athletes (including young women) who want BTB-level security without BTB kneeling pain, and in revision when hamstrings are already used.

Graft 04

Rectus femoris tendon

An emerging option Mr Riaz offers

The rectus femoris is one of the four quadriceps muscles; its tendon can be harvested high in the thigh to give a long, thick, tubular graft — strikingly close to the native ACL in shape and composition — while leaving the hamstrings, patellar tendon and the rest of the quadriceps untouched. I offer it in selected cases: chiefly revision ACL where other sites are used, and patients needing to preserve hamstring strength. It is emerging — early results are promising, long-term comparative data does not yet exist, and I am honest with patients about that.

Graft 05

Peroneus longus tendon

Selected cases — not primary ACL

Half of the peroneus longus tendon from the outside of the ankle — a strong graft that leaves the knee untouched, popular in parts of Asia and increasingly discussed online. The honest position: short-term results are encouraging, but there is no proven superiority over standard knee grafts, and it borrows from a tendon that stabilises the ankle and supports the arch of the foot. I treat it as a useful option for revision and multi-ligament cases where knee donor sites are exhausted — not a routine first choice.

Graft 06

Allograft (donor tendon)

Selected older / lower-demand patients

Sterile, screened tendon from a tissue donor — no harvest, no donor-site pain, shorter surgery. The catch is biology: donor tissue incorporates more slowly, and in young, active patients the failure rate is roughly three times higher than autograft — so I do not use it for young athletes’ first reconstructions. In the right knee it is excellent: older or lower-demand patients wanting the easiest recovery, complex multi-ligament injuries, and revisions where autograft is exhausted.

Graft 07

Synthetic ligament — the JewelACL™

Made in Leeds • fastest return

Synthetic ACLs have a chequered history — the devices of the 1980s and 90s failed often and gave “artificial ligaments” a deservedly bad name. The JewelACL is a new generation: a polyethylene terephthalate (PET) fibre ligament engineered and made by Xiros in Leeds, with a fibre architecture designed to address exactly those old failure modes. It can be used standalone or as a hybrid with your own tendon. Its appeal is no donor site at all and immediate strength, allowing accelerated rehabilitation — which is why it has a role in selected professional athletes and older patients prioritising the fastest return. A randomised trial versus hamstring autograft is now published, and hybrid results are encouraging — but long-term evidence is still accumulating, and I discuss that openly.

Which ACL graft has the lowest re-rupture rate?

In young athletes returning to pivoting sport, registry data favours patellar tendon (BTB) — roughly 5% versus 11% for hamstring in under-25s. But re-rupture is not the only outcome that matters: kneeling pain, strength and recovery differ too, and adding a LET substantially reduces re-rupture risk for hamstring grafts. That is why the “best” graft is individual.

Will taking my hamstring or quads tendon permanently weaken my leg?

Every autograft borrows from somewhere and leaves a small, measurable deficit. For most people it is not noticeable in daily life or sport after rehabilitation; for sprinters, martial artists and kneeling trades it genuinely changes which graft I recommend. The tendons themselves regenerate to a surprising degree.

Are synthetic ligaments safe? I read they all failed.

The synthetic devices of the 1980s and 90s did fail at unacceptable rates, and that history deserves respect. The modern JewelACL is a different fibre architecture, engineered to address those failure modes, with randomised and hybrid-use studies now published — but decades-long evidence does not yet exist. I offer it in carefully selected patients with an honest conversation about exactly that.

Can I choose my own graft?

Yes — within honest limits. My job is to give you the evidence as it applies to your knee, your sport and your life, tell you what I would do in your position, and flag when a preference carries real risk. The final decision is made together.