Sports Docs Weekly Blitz: ACL Reconstruction Graft Selection

As basketball season gets started, I wanted to briefly discuss one of the most common basketball (and football, too, for that matter) injuries that often needs surgery: The ACL.

The ACL, as most sports enthusiasts probably already understand, is a ligament inside the knee that helps stabilize the knee joint, especially during cutting and pivoting motions.

When the ACL in disrupted, the tibia (shin bone) can slide forward or rotate relative to the femur (thigh bone). Unfortunately, the ACL has a very poor blood supply, and this compromises the body’s healing potential of a torn ACL. Furthermore, because of the poor blood supply and thus poor healing potential, repairing the native ACL does not predictably work well.

This is why ACL “Reconstruction” is the most common surgery for ACL injuries. “Reconstruction” means we, as orthopedic surgeons, are replacing the injured ACL ligament with an entirely new graft, such that we don’t need to rely as heavily on the blood supply for healing. We have addressed the topic before, but today I wanted to touch on one of the important decisions surgeons and patients make leading up to surgery…which graft to use??

Three commonly used grafts used in ACL Reconstruction are the:

  • Bone-Patella Tendon-Bone (“BTB”) graft
  • Hamstring graft
  • Cadaver graft ( donated tissue is transplanted into the knee)

A fourth graft option is gaining popularity, especially in revision surgery settings, and that is the quad tendon graft. The BTB and Hamstring grafts are 2 of the most common types of grafts used in competitive athletes. The graft is harvested from the athlete’s knee and then used to replace, or “Reconstruct”, the torn ACL.

The cadaver donor graft can be a consideration if the patient does not want to use his/her own tissue for the graft, and that decreases the pain and morbidity associated with the graft harvest. There are pros and cons to each graft type, and I tailor graft selection to each patient. In general, I like to use the BTB for high level cutting athletes. This is probably the most common graft choice in professional sports in the US including the NFL.

There are certain situations, however, where I prefer the hamstring graft, such as in wrestlers, who compete on their knees which can irritate the BTB harvest site. In less active patients, there is now an “all-arthroscopic” technique that I use with donor grafts with which my patients have been very happy.

So, which is the best graft? This is a much-debated topic in Sports Medicine, and ultimately, all commonly used graft types have generally good outcomes. In my practice, I try to tailor each ACL surgery individually by helping my patient pick the graft that suits them the best in terms of all the risks and benefits of each graft type and surgical technique. This is a HUGE topic that books and books have been written on, and this is just a primer that I hope helps you understand the ACL injury and surgery just a little bit better.

That’s all for now, Doc Warme.


Dr. Bryan Warme


Dr. Warme treats all athletic injuries and specializes in arthroscopic reconstruction of the Shoulder, Elbow, Hip, Knee and Ankle. He provides orthopedic coverage for Iowa State's athletes and area high school athletes. Having been an athlete himself who had to work through various injuries and surgeries, he is committed to giving athletes the best care possible with the goal of getting them back on the field competing at the highest levels. His approach is to treat all his patients as if they were members of his own family. Dr Warme Specializes in: Sports Medicine Consultant to ISU Athletic Teams Arthroscopic Reconstruction:shoulder, elbow, hip, knee and ankle