Choosing between patella vs hamstring as a graft for ACL surgery can be a difficult decision. At a glance the options seem fairly balanced, with pros and cons on either side, but our two polls have shown a slight leaning toward hamstring graft. Below is what people commonly say among the choices:
1. PATELLAR GRAFT – the old-school gold standard and choice of many athletes.
Pros: The patellar graft is strong, as the graft from the knee tendon includes bone which ‘fuses’ into your knee nicely. It also resembles the size and length of the ACL (anterior cruciate ligament) that is needed and is technically easier for a surgeon to do this. Fast recovery.
Cons: May give you knee pain. Many people complain that kneeling or bending the knee causes pain that wasn’t there before.
Summary: Patellar graft may be the best choice for young people who are engaged in professional or high-impact sports and are willing to risk having knee pain for perhaps the rest of their life. It may not be a good choice for a working man, such as a carpenter, who bends their knees a lot, crawling in tight spaces, or walking up and down stairs all day.
2. HAMSTRING GRAFT – considered a newer technique that claims comparable strength to the patellar graft, but without the knee pain.
Pros: Less or no knee pain, comparable strength to patellar.
Cons: Slightly weaker hamstring muscle- 90% of normal strength. Some people complain that the hamstrings stretched out and no longer becomes tight. May take longer rehab.
Summary: Hamstring graft is the best choice for someone middle of the road, who does physically active sports, but not professionally or extremely competitive. This person is not as much in a time-crunch to recover, and the priority is in not having knee pain.
3. ALLOGRAFT (graft from a frozen cadaver) – the doctor likely takes a patellar graft from the cadaver to use in the knee of the patent.
Pros: Fast recovery from surgery, as you don’t sustain any injury by having a graft taken out of your own body.
Cons: Weaker- a low percentage of patients have the allograft break, requiring a 2nd ACL surgery. Has a slight risk of getting a disease transmitted through the blood & body part from someone else.
Summary: Allograft is the best choice for someone aged 45+ or someone who does not plan to do any substantial physical sports, and is willing to take the risk of implanting someone else’s body part.
Note: Doctors generally specialize in either patellar graft only or hamstring graft, and generally don’t perform both. So, when you choose a doctor, you’re also choosing what graft you want. To change grafts, you likely have to change your doctor completely. Because of a higher technical skill involved in the hamstring graft, it may mean you will find more competent doctors performing it.
Reputable doctors may contradict each others’ opinions. One may say patellar graft is best, the other may say the hamstring graft is best. Online research suggests there’s no strong winner on either side, but perhaps a slight leaning towards the hamstring graft.
Doctor A says:
- Hamstring graft is the most popular choice for professional athletes today
- There’s less risk of graft complication
- No knee pain with hamstring graft, where as, the patellar commonly results in a lifetime of pain when kneeling
- Hamstring graft is stronger than the patellar, because of 4 dense strands bound together, instead of just 1 with the patellar
- Neither grafts ‘grow back’, so better to go with the hamstring, since it’s a very large size and taking such a small portion of it only results in a hardly detectable loss of strength 5% – 10%, but it’s easily regained through basic physical therapy
- The drilling hole in the bone can be smaller when using the hamstring graft, because of the efficient configuration of the 4 strands in the hole. A smaller hole, results in a stronger bone
- Patellar grafts can loosen/weaken the knee and lead to patella arthritis
- Patellar grafts are ‘old school’ – a thing of the past. This surgeon used these grafts years ago, but not since the advancements in hamstring grafts, which are now superior
- Tiger Woods had a hamstring graft
- Hamstring grafts are the best
Doctor B says:
- Patellar graft is a larger and stronger tendon that’s 10mm, instead of a 8mm hamstring graft
- Patellar graft is the most popular choice among athletes today
- An annual survey of hundreds of orthopedic surgeons shows that patellar grafts are most popular
- Patellars are the ideal size and length
- The hamstring is too small, too long, and requires a more technical procedure with greater opportunity for error
- The hamstring may stretch/loosen and may not fasten to the bone correctly over time
- The patellar actually grows back and regenerates itself in 8 months, where as, the hamstring will be gone forever and be noticeably weaker
- Tiger Woods only got a hamstring graft only because the surgeon he chose invented his own hamstring graft technique which he wanted to promote
- Patellar grafts are best
As you can see, there’s good reason to hesitate when making a choice with potential long-term health ramifications.