The anterior cruciate ligament (ACL) is one of the four main ligaments that stabilize the

knee and hold the femur and the tibia together. (Physiology of the ACL) Like everything in the
body, the ACL can be damaged. Usually, the ACL will rupture (tear). This is due to trauma to
the lateral or posterior portion of the knee, hyper-extension or rotation of the knee, or poor
landing mechanics. Because the ACL is poorly vascularized (poor blood supply), it cannot
promote self-healing. There are two therapy options for ACL tears: ACL reconstruction surgery
or physical therapy to strengthen the surrounding muscles to compensate the loss of an ACL.
For young, active patients, reconstruction surgery is highly recommended. Because the patient is
young, the body will recover from the surgery faster than an older patient (50 years and older).
In addition to the patient being young, the patient is active, which means involved in physical
activities (sports, running, weight lifting, etc.). Strengthening the surrounding muscles to
compensate for the ACL will, not only be ideal, it can cause further problems. The surgeon
performing ACL reconstruction surgery will have a choice to make; what type of graft will he or
she use to substitute as an ACL? A graft is a piece of living tissue that is transplanted surgically.
There are four different types of grafts that a surgeon can use, but in a young, active patient the
two best grafts are bone-patellar tendon-bone autografts (auto = self) and hamstring tendon
autografts. There is much debate between which graft is better, but research has supported
hamstring tendon grafts more than BTB patellar tendon grafts.
The hamstring is made up of three muscles: the semitendinosus, semimembranosus, and
the biceps femoris. These muscles originate from the ischial tuberosity of the pelvic bone. The
semitendinosus and semimembranosus insert into the medial chondyle of the tibia via the
semitendinosus and semimembranosus tendon. The semitendinosus tendon inserts into the
medial chondyle of the tibia just inferiorly (below) the gracilis tendon, both of which are used for

the ACL graft. This muscles are responsible for flexion of the knee, or bending of the knee.
They are located on the posterior portion (back) of the leg, superior (above) to knee. When the
surgeon needs to harvest the graft, he or she will begin with an incision below the knee, where
the semitendenosus tendon and the gracilis tendon insert onto the tibia, and will extract that
portion. Surgeons use tendons as replacements for ligaments because, like the ligament, they are
classified as connective tissue. Connective tissue is different from different types of tissue
because they contain contain collagen fibers, which allow elasticity but also rigidness and
strength. Plus with tendons, they can be split two and stitched together whereas other ligaments
are scarce. Hamstring autografts have the least amount of pain associated with it postoperatively. There are the same amount of incisions with a hamstring graft and a patellar tendon
graft, but the incisions are a lot smaller in a hamstring graft. Compared to BTB grafts, quadracep
activiation occurs faster. This is due to the fact that the four quadracep muscles that insert into
the tibial tuberosity, go through the patellar tendon. The patient must avoid using the quad
muscles for awhile to allow the patellar tendon to recover. Finally, the hamstring tendon graft
provides the strongest tensile strength, 4500 Newtons to failure. Although, the hamstring tendon
graft is not perfect; it has its own share of flaws. Initially, the graft is not anchored in as strong
as the patellar tendon graft. The patellar tendon graft has to bone fragments located on each end.
The bone fragments on the ends of the graft improve the anchor point of grafts within the femur
and the tibia. Also, even though the quad muscle activation occurs faster in rehab, hamstring
tendon graft patients are not even allowed to activate their hamstring muscle because they need
to allow the tendons to recover, this allows muscle atrophy (degeneration of muscle due to lack
of use) to occur within the hamstring. Recent improvement of surgical techniques have brought
hamstring tendon grafts as a viable option for surgery.

The second type of graft is the bone-patellar tendon-bone graft. This graft requires the
harvesting of central third of the patellar tendon. This is done creating an incision starting from
the posterior border of the patella and cutting down twenty-five millimeter down to the tibial
tuberosity. The tendon is then extracted and the surgeon enters the knee joint arthroscopically,
clears the debris of the old ACL, drill the holes within the femur and tibia for the graft to enter,
and secure graft in the proper ACL position. With a patellar tendon graft, the interface within the
joint is strong. Both contacts of the graft have bone integrated in it, only requiring the surgeon to
drill bone plugs to lock in the graft in place. Because of this strong interface, weight bearing and
range of motion can begin when tolerable. Patellar tendon grafts have been the gold standard for
quite some time, since the mid 1980s. Surgeons are more comfortable with the procedure and it
is easier to perform compared to the hamstring graft.
Other than the fact that the initial fixation of the graft and patients can return to sports a
lot quicker than hamstring grafts, the patellar tendon graft has more disadvantages than
advantages. It is the most painful of the two surgeries due to the long incision and causes a lot of
knee problems as the patient gets older. Doctors continue to support patellar tendon grafts
because it is suppose to be more stable than hamstring tendon grafts. But research has concluded
that both grafts offer the same amount of stability, though they both have the same drawback. If
the donor site is compromised, the graft itself will not work. "The patellar tendon graft has been
associated with doner-site morbidity such as anterior knee pain, loss of sensation, patellar
fracture, inferior patellar contracture, and loss of extension torque (hindawai)." The tensile
strength of the patellar graft may lead to degenerative arthritis.
Surgeons are split between the patellar tendon graft and the hamstring tendon graft. Both
sides offer their advantages and disadvantages, but hamstring tendon graft has more advantages

than disadvantages. And the disadvantages are not as debilitating as the patellar tendon graft.
Though the procedure is more difficult to do, due to the fact that the surgeon has to cut through
two tendons and extract them properly, it is worth it for a surgeon to learn the procedure and use
a hamstring tendon graft. Because of recent developments in surgical procedure, the hamstring
graft has become popular. Now, surgeons will begin testing new procedure and seeing research
using this graft will become more readily available. This is not to say scientific discoveries with
the patellar graft will not happen, new procedures and information will, more than likely, support
hamstring tendon grafts rather than patellar tendon grafts.