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ACL Surgical Choices: What Are My Options?

March 27, 2012

If you’ve injured your anterior cruciate ligament (ACL), one of the treatment options is surgery.

Not all ACL injuries results in surgery.

But what kind of surgery options are there for ACL injuries? Let’s explore four and who are typically good candidates for the surgery.

Patellar Tendon Autograft (PTA)

The gold standard for ACL reconstruction, the PTA involves a third of the middle patellar tendon, a bone plug from the shin and kneecap of the patient. You’ll see high-performance, professional athletes undergoing this type of surgery.

You’ll also see patients whose jobs don’t demand they kneel a lot get this surgery, too.

The PTA has a lower rate of failure compared to the hamstring autograft (1.9 percent v. 4.9 percent) and shows better knee laxity in tests when compared to other surgeries. However, this surgery is known for a higher rate of pain behind the knee, pain when kneeling and slightly increased risk of stiffness after surgery.

Hamstring Tendon Autograft

The hamstring tendon on the inner side of the knee is used for this ACL reconstruction autograft. The gracilis, a tendon attached below the knee, is sometimes used by surgeons, creating a tendon that is made up of two or four strands. This ACL surgery is often used because of the ease in which surgeons can harvest the hamstring tendon.

There is also fewer problems knee or kneecap pain after surgery, less stiffness, a smaller incision is used and leads to a faster recovery. Some studies suggest that this surgery leads to stretching of the tendon and a lessening of strength in the patient. Hypermobile patients (those with knee hyperextension over 10 degrees or an intrinsic ligamentous laxity) are recommended to proceed with the PTA surgery.

Quadriceps Tendon Autograft

For patients who have failed previous ACL reconstruction, the quadricep tendon autograft is used. A bone plug from the knee cap and the middle third of the quadricep tendon are used, allowing for a larger graft for heavier, taller candidates. The fixation is not as solid as the PTA since there is only one bone plug. While their is a low risk of patella fracture, their is a high risk of post-surgery anterior knee pain. And the incision can be pretty ugly.


This is becoming a popular procedure for first time ACL surgery patients, but as well as for those who have failed previous ACL reconstruction. This is also used when there is more than one knee ligament to be repaired.

There is no pain to the patient from harvesting a ligament from their body, there is less recovery time and the incisions are not as big.

However, the patellar tendon allograft does provide a stronger bony fixation, with screws. There is an association with infection risk with allografts including HIB and hepatitis C. Careful screening and processing doesn’t always catch the infections. Deaths linked to improper sterilization of allograft tissue are also associated with allografts. And the failure rate is also very high at 23% to 35%, this among patients who are young playing high-demand sports.

It’s unclear why the failure rates are so high, but possibilities include a too-soon return to sports or problems with the graft itself…like donor age or how the graft was stored.

Dr. Rick Lehman is a distinguished orthopedic surgeon in St. Louis, Missouri and an articular cartilage reconstruction pioneer. He owns U. S. Sports Medicine in Kirkwood, MO, and LehmanHealth. Learn more about Dr. Rick.

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