Review Article

Autografts Commonly Used in

Anterior Cruciate Ligament
Reconstruction

Abstract
Walter R. Shelton, MD Anterior cruciate ligament reconstruction is among the most
Bryan C. Fagan, MD common orthopaedic procedures in the United States, with
>200,000 performed annually. Much has been published regarding
the use of autograft versus allograft. Bone–patellar tendon–bone is
the most frequently used autograft, but hamstring and quadriceps
tendon grafts are common alternatives. Each graft has distinct
advantages and disadvantages, and selection is individualized.
Fixation methods vary by graft type. Fixation resulting in a
construct that is too rigid may restrict knee range of motion. Donor
site morbidity must be considered, as well. Autograft harvest may
result in anterior knee pain, kneeling pain, anterior knee numbness,
muscle weakness, and patellar fracture. Appropriate graft selection
is essential to optimize outcomes.

M ore than 200,000 anterior

From Mississippi Sports Medicine
and Orthopaedic Center, Jackson,
MS (Dr. Shelton) and North East
Orthopaedics and Sports Medicine,
Tupelo, MS (Dr. Fagan).
Dr. Shelton or an immediate family
member serves as a board member,
owner, officer, or committee member
of the Arthroscopy Association of
North America, and is a member of
a speakers’ bureau or has made
paid presentations on behalf of and
serves as an unpaid consultant to
Smith & Nephew and Zimmer.
Dr. Fagan or an immediate family
member serves as a paid consultant
to or is an employee of Smith &
Nephew.
J Am Acad Orthop Surg 2011;19:
259-264
Copyright 2011 by the American
Academy of Orthopaedic Surgeons.
cruciate ligament (ACL) re-
constructions are performed each
year in the United States, which
places it among the top 10 surgical
procedures in orthopaedics in terms
of frequency.1 Surgical technique has
changed in the past 30 years, result-
ing in a current focus on restoration
of the natural anatomy and function
of the ACL. The goals of ACL recon-
struction are to achieve adequate
strength, reproduce the insertional
anatomy of native ACL, allow secure
initial fixation, and promote rapid
revascularization and maturation.
Minimizing donor site morbidity is
an important factor in graft selec-
tion. Allograft is a popular alterna-
tive to autograft because it lacks the
donor site morbidity associated with
autograft. However, allografts are
associated with increased cost,
slower incorporation time, increased
risk of disease transmission, and a
higher failure rate. Most ACL recon-
structions involve harvest of au-
tograft patellar, hamstring, or quad-
riceps tendon. Each of these graft
types has weaknesses and strengths,
and the grafts can be compared on
the basis of biomechanical proper-
ties, donor site morbidity, fixation
properties, complications, and re-
sults.
Biomechanics
The perfect graft would reproduce
the characteristics of native ACL.
Graft biomechanical properties have
been extensively studied, but results
differ because of variable testing
methods. Factors that may affect re-
sults include graft size, direction of
the applied load, age of the donor,
and graft fixation. The number of
variables involved makes direct com-
parison of different studies difficult.
Noyes et al2 demonstrated that na-

May 2011, Vol 19, No 5 259

Autografts Commonly Used in Anterior Cruciate Ligament Reconstruction
tive ACL had an ultimate load to
failure of approximately 1,725 N.
Woo et al3 later reported that the ul-
timate load to failure was higher
when the ACL was tested in its ana-
tomic orientation (approximately
2,106 N). Bone–patellar tendon–
bone (BPTB) grafts have an average
width of 10 mm and thickness of 4
mm.4 BPTB grafts of this width have
been shown to have an ultimate load
to failure of 2,977 N, which is
greater than that of native ACL.
Wider grafts are even stronger; how-
ever, the risk of patellar fracture and
notch impingement prevents most
surgeons from harvesting a wider
graft. Rotating the graft 90° also in-
creases its strength.4 Because of its
thickness and the bone plugs at-
tached to both ends, BPTB graft is
not a good choice for double-bundle
ACL reconstruction.
In contrast to BPTB graft, the ulti-
mate load to failure of semitendino-
sus and gracilis tendon grafts has
been reported to be 1,216 and 838
N, respectively.2 Because these grafts
individually are weaker than native
ACL, the technique of doubling both
grafts to produce a quadruple-strand
composite has become popular. The
strength of this composite has been
reported to be between 2,422 and
4,590 N.5,6 The loops of the tendon
must be equally tensioned to achieve
full strength. Braiding of a quadru-
pled hamstring graft is not recom-
mended because it reduces the
strength of the graft.7 Hamstring ten-
dons are an excellent choice for
double-bundle ACL reconstruction.
A doubled semitendinosus graft is
used for the anteromedial bundle,
and a doubled gracilis graft is used
for the posterolateral bundle.
On average, quadriceps tendon
graft is 10 mm wide and 7 mm thick.
West and Harner8 reported the ulti-
mate tensile load of a 10-mm–wide
quadriceps graft to be 2,352 N. Lon-
gitudinal division between the vastus
260
intermedius tendon and the rectus
femoris tendon produces an excellent
graft source for double-bundle ACL
reconstruction. The larger rectus
femoris is used to reconstruct the an-
teromedial bundle, and the smaller
vastus intermedius tendon is used for
the posterolateral bundle. A layer of
fat separates the two tendons in the
proximal part of the graft, which
makes longitudinal separation of
them easy.
Graft Fixation
Forces acting on an ACL graft can
reach 450 to 500 N during early re-
habilitation.8 All three commonly
used autografts exhibit load-to-
failure values of >2,000 N.8 The
weakest component of ACL recon-
struction is the method of fixation.
Tibial side fixation is typically the
weakest method because of the can-
cellous bone found in the tibial me-
taphysis.9
Fixation of BPTB graft with bone
plugs on both ends and interference
screws produces a strong construct.
No difference in clinical outcomes
has been found between metal and
absorbable screws.10 Pullout strength
of BPTB graft varies depending on
the strength of the native bone.
Caborn et al11 reported load-to-
failure values of 558 ± 67.9 N with
bone block fixation using an interfer-
ence screw; these values are close to
the stress experienced during normal
early rehabilitation. Conversely,
there is concern that a construct that
is too rigid may restrict ultimate
knee range of motion (ROM), possi-
bly resulting in loss of full extension.
For this reason, Shelbourne and
Gray12 recommended using sutures
tied over buttons on both sides of the
graft for BPTB fixation.
Fixation of hamstring grafts with
sutures over buttons, sutures over
posts, staples, washers, and interfer-
Journal of the American Academy of Orthopaedic Surgeons
ence screws has been described, as
well as femoral side fixation with
cross pins. A variety of commercial
devices has been developed for use
with these techniques (eg, BioScrew
[ConMed Linvatec, Utica, NY];
Bone Mulch Screw [Biomet, Warsaw,
IN]) with pullout strength >500 N.8
However, no study has reported a
statistically significant improvement
in clinical outcomes with one
method compared with any other.
Soft-tissue fixation with hamstring
graft results in less rigid constructs
than fixation with BPTB graft.13 This
may explain the slight increase in
laxity reported in hamstring grafts
compared with BPTB.13 Conversely,
it may also explain why better exten-
sion is reported with hamstring
grafts.13
Quadriceps tendon grafts can be
used as free grafts.14 Alternatively, a
bone plug may be used on one side.
When a bone plug is used, an inter-
ference screw is used to achieve fixa-
tion, similar to BPTB fixation. The
opposite end is soft tissue, and fixa-
tion is usually achieved with interfer-
ence screws or sutures tied over a
post.
Donor Site Morbidity
Donor site morbidity is a distinct dis-
advantage of using autograft for
ACL reconstruction. Harvest site
morbidity includes anterior knee
pain, kneeling pain, patellofemoral
crepitus, anterior knee numbness,
patellar fracture, tendon rupture,
and muscle weakness. Unique surgi-
cal morbidities associated with the
harvest of BPTB, hamstring, and
quadriceps tendon grafts have been
extensively studied and compared
(Table 1).
Anterior knee pain following BPTB
harvest is a significant problem. Pin-
czewski et al15 and Freedman et al16
reported that the incidence of ante-
 Walter R. Shelton, MD, and Bryan C. Fagan, MD

Table 1
Factors to Consider in Anterior Cruciate Ligament Autograft Selection
Anterior Anterior Knee Failure Knee Residual Patient
Graft Type Knee Pain Numbness Rate Tightness Weakness Extension Satisfaction

BPTB High High Low High Quadriceps High High

muscle
Hamstring Low Low Slightly Slightly lower Hamstrings Low High
higher
Quadriceps Low Low Low High Quadriceps Low High
muscle

BPTB = bone–patellar tendon–bone

rior knee pain was significantly
higher with BPTB graft than with
hamstring graft (P = 0.05 and P =
0.007, respectively). Other studies
suggest that little difference exists in
the incidence of anterior knee pain
between BPTB and hamstring
grafts.17,18 The pain described in
these studies is likely secondary to
chondromalacia patella, which is
common after ACL reconstruction
regardless of graft type. Geib et al19
and Han et al20 found the incidence
of anterior knee pain to be signifi-
cantly lower with quadriceps tendon
autograft than with BPTB (P = 0.05
and P < 0.05, respectively). Both
studies reported a nearly fivefold in-
crease in anterior knee pain with
BPTB compared with quadriceps ten-
don autograft. Lee et al21 found the
incidence of anterior knee pain to be
similar between quadriceps tendon
and hamstring tendon autograft.
Kneeling pain, which is defined as
pain produced by direct pressure on
the patellar tendon, has been studied
independent of generalized anterior
knee pain. Kneeling pain is detected
by having the patient walk on his or
her knees. Goldblatt et al22 and Spin-
dler et al23 found significantly in-
creased kneeling pain associated
with BPTB compared with hamstring
graft. At 2-year follow-up, Ejerhed
et al17 reported kneeling pain in
nearly twice as many patients who
underwent ACL reconstruction with
BPTB graft compared with those
who received hamstring autograft. In
a study by Kim et al,24 kneeling pain
was reported in 13 of 27 patients fol-
lowing BPTB graft, compared with 4
of 21 patients treated with quadri-
ceps graft (P = 0.029).
Residual donor site weakness is an-
other concern associated with au-
tograft harvest. The quadriceps mus-
cle is substantially weakened after
harvest of BPTB and quadriceps ten-
don grafts. Strength deficits of 20%
at 1-year follow-up and 15% at 3
years have been reported.21 MRI as-
sessment at 1-year follow-up has
shown scar tissue and hypertrophy in
both graft donor sites. Hamstring
harvest also leads to measurable
weakness in knee flexion strength.18
Hamstrings are the major dynamic
stabilizer of the knee and prevent
anterior translation of the tibia on
the femur. Inadequate hamstring
strength may be a contributing factor
in acute ACL tears and ACL graft
rupture.
Numbness of the anterior knee is
caused by injury to the infrapatellar
branch of the saphenous nerve dur-
ing graft harvest. Injury to the nerve
may occur with arthroscopic portal
placement or the incision made to
harvest BPTB grafts. The incidence
of anterior knee numbness is dramat-
ically lower with hamstring and
quadriceps graft harvest than with
BPTB harvest because incisions made
to harvest hamstring and quadriceps
grafts do not disrupt this nerve. In a
review of 198 primary ACL recon-
structions, symptomatic anterior
numbness was reported in 53% fol-
lowing BPTB harvest compared with
1.5% following quadriceps tendon
harvest.19
Patellar fracture has been reported
with BPTB and quadriceps tendon
graft with bone plug.21,25 Fulkerson
et al14 advocated the use of a free
quadriceps tendon graft to reduce
morbidity. However, Geib et al19
showed no difference in clinical out-
comes with or without a bone plug.
When BPTB or quadriceps tendon
graft is used with a bone plug, the
patellar defect should be grafted with
bone from tunnel reamings.19
Results
Results of ACL reconstruction with
BPTB, hamstring, and quadriceps
tendon graft can be analyzed with re-
gard to stability, ROM, complica-
tions, and patient satisfaction (Table
1). Most studies show no difference
in anterior laxity, functional results,
and International Knee Documenta-
tion Committee (IKDC) scores re-
gardless which graft is used.14,19,26,27
However, some differences have been
reported.
Three meta-analyses demonstrated
a trend toward better arthrometer

May 2011, Vol 19, No 5 261

Autografts Commonly Used in Anterior Cruciate Ligament Reconstruction
Figure 1
Photograph of a quadriceps tendon
with a bone plug graft.
values, Lachman tests, and pivot
shift examinations with BPTB com-
pared with hamstring graft.16,22,23
Most studies show no significant
clinical differences in overall results
between BPTB and hamstring
graft.17,27-29 BPTB graft is associated
with superior IKDC scores,27,30
higher Tegner scores,29 and lower
failure rates.16 However, complica-
tions associated with BPTB graft in-
clude patellar fracture,21 patellar ten-
don rupture,21 and greater extension
lag.31
Hamstring graft has been associ-
ated with better extension, a lower
incidence of long-term degenerative
joint disease,15,32 and better extension
strength29 than both BPTB and quad-
riceps grafting. In a study of endo-
scopic reconstruction using quadruple-
strand composite hamstring graft, 98
of 113 high-performance athletes re-
turned to preinjury level of activity.33
However, compared with BPTB
graft, hamstring grafts are associated
with a greater loss of knee flexion
strength29 and higher failure rates,34
especially in females.35
Quadriceps tendon grafts have re-
cently been the focus of considerable
attention. Lee et al21 reviewed 247
patients who underwent ACL recon-
struction with a quadriceps tendon
graft with bone block. At a mini-
mum 2-year follow-up, stability,
ROM, and IKDC scores were similar
to those with BPTB. No change in
knee ROM was reported (mean,
262
Figure 2
Photograph of a free quadriceps
tendon graft.
137.3° preoperatively versus 137.5°
postoperatively). Eighty-seven per-
cent of patients had an IKDC score
of grade A or B. Quadriceps strength
was 81.8% of normal at 1-year
follow-up and improved to 91.2% at
3 years. The failure rate was 2.9%,
and one patient experienced patellar
fracture. Biopsy of 37 quadriceps
tendon with bone plug grafts ob-
tained at second-look arthroscopy
showed a bimodal pattern of large-
and small-diameter fibrils similar to
the pattern present in native ACL. A
unimodal pattern of small collagen
fibrils has been demonstrated in al-
lograft and mature BPTB autograft.
Large fibrils are necessary for high
tensile strength; loss of these fibrils is
associated with a high rate of liga-
ment failure.21
Geib et al19 reviewed 198 quadri-
ceps tendon grafts at an average
56.6-month follow-up. Statistically
significant improvement was re-
ported in extension and with ar-
thrometer values of ≤3 mm (P = 0.01
each). Anterior knee pain and numb-
ness were lower with quadriceps ten-
don graft than with BPTB graft (P =
0.05 and P = 0.01, respectively). No
difference in results was reported
based on patient sex or the presence
or absence of a bone plug. Three
other studies reported similar results
between quadriceps tendon and
BPTB grafts with respect to IKDC
scores, stability, and Lysholm
scores.20,24,36
Journal of the American Academy of Orthopaedic Surgeons
Authors’ Preferred Graft
and Fixation Method
In the past 12 years, the senior au-
thor (W.R.S.) has exclusively used
quadriceps tendon autograft for ACL
reconstruction. During the first 6
years, a bone plug harvested from
the patella on one end was used. For
the past 6 years, free quadriceps ten-
don autograft without a bone plug
has been used. We have found no
statistical difference in outcomes re-
gardless whether a bone plug is used
(Figures 1 and 2).
Interference screw fixation is per-
formed on both the femoral and tib-
ial sides. On the femoral side, a
9-mm socket and a 7- × 25-mm ab-
sorbable interference screw are typi-
cally used for fixation. On the tibial
side, the two tails of the graft are
split between the vastus intermedius
tendon and the rectus femoris ten-
don. These tendons are separated,
and an interference screw is inserted
into the tibial side between the two
grafts. A 10- × 28-mm bioabsorbable
interference screw is inserted into the
aperture of the tibial tunnel between
the ends of the two tendons. This
method produces a graft that is 10
mm wide and 7 mm thick. At a mini-
mum 2-year follow-up, outcomes of
ACL reconstruction with this graft
were equal to those of a similar set
of BPTB reconstructions done by the
senior author.19
Summary
ACL reconstruction with BPTB,
hamstring, and quadriceps tendon
autografts is successful in most cases.
Each graft has advantages and disad-
vantages.
BPTB autograft affords the most
secure fixation, a low failure rate,
and a high rate of patient satisfac-
tion. However, it is associated with
increased anterior knee pain and

numbness, with a greater incidence
of extension loss. Quadrupled ham-
string grafts are associated with ex-
cellent outcomes, with less anterior
knee pain and numbness than with
the other graft types. However, qua-
drupled hamstring grafts are associ-
ated with a slightly higher degree of
laxity than are BPTB grafts, espe-
cially in females. Hamstring harvest
weakens knee flexor strength and
may be a factor in the reported inci-
dence of graft failure. Quadriceps
tendon grafts have a low incidence of
anterior knee pain and numbness,
and clinical outcomes are excellent.
Instrumented tested laxity in men
and women is equal to BPTB with-
out a corresponding loss of exten-
sion.
Graft selection should be individu-
alized based on the benefits and
drawbacks of the available grafts.
Surgeon experience, patient activity
level, and patient preference should
be considered, as well.
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Evidence-based Medicine: Levels of
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