Why your graft choice matters

There is no single "best" ACL graft. All four common autografts (your own tendon) give good results; what differs is where the graft is taken from, the trade-offs at that site, and the risk of re-tear in young, high-demand athletes.

In ACL reconstruction, the surgeon replaces your torn ligament with a tendon. The four autograft options are the hamstring, the bone–patellar tendon–bone (BTB), the quadriceps tendon and the peroneus longus tendon from the outer ankle. Over the following 6 to 12 months the graft remodels into ligament-like tissue, and it is most vulnerable during this period.

In India, many patients return to pivoting sports such as football, cricket, badminton, basketball and kabaddi, and many kneel or sit cross-legged daily. Both factors shape which graft suits you best.

How the four grafts stack up

	Hamstring	BTB (patellar tendon)	Quadriceps tendon	Peroneus longus
Harvest site	Back and inner thigh	Front of knee, with bone from kneecap and shin	Above the kneecap	Outer side of the lower leg, above the ankle
Healing in the tunnels	Tendon to bone	Bone to bone	Tendon to bone (bone to bone if a bone block is taken)	Tendon to bone
Graft size	Variable; may be under 8 mm	Consistent	Large	Large, often larger than hamstring
Re-tear / revision risk	Higher in young athletes, especially with small grafts	Lowest in large registries	Similar to BTB and hamstring in trials	Similar to hamstring in short- to mid-term studies
Front-of-knee and kneeling pain	Low	Highest	Low; much lower than BTB	None at the knee
Main strength trade-off	Hamstring weakness	Early quadriceps weakness	Early quadriceps weakness	Possible mild ankle eversion weakness
Length of evidence	Decades, large registries	Longest, decades	Growing; mostly 2–5 years	Shortest; mostly Asian series up to 5 years
Often suits	Recreational athletes, people who kneel, adolescents with open growth plates	Competitive pivoting athletes who can tolerate kneeling discomfort	Young, high-demand athletes; revision surgery	Thin hamstrings; desire to avoid knee donor-site morbidity; revision and multi-ligament surgery

The sections below give the evidence behind each row.

Hamstring graft

The semitendinosus tendon, often with the gracilis, is taken through a small incision below the knee and folded into a four-strand (or larger) graft. It is the most widely used graft worldwide: 84% of reconstructions in the Scandinavian registries (Gifstad et al., 2014).

Advantages: small scar, little front-of-knee or kneeling pain, easier early rehab, and fixation options that spare growth plates in adolescents.

Trade-offs:

Graft size matters. Every 0.5 mm increase in graft diameter between 7 and 9 mm lowered the odds of revision by about 18% in a large US registry (Spragg et al., 2016). In patients under 20 with grafts of 8 mm or less, revision rates reached about 16% (AJSM review).
Higher revision risk than BTB. Among 45,998 Scandinavian reconstructions, hamstring grafts had a significantly higher risk of revision than BTB (Gifstad et al., 2014).
Hamstring weakness can persist, relevant for sprinters and fast bowlers.

Adding a lateral tenodesis. In young, high-risk patients, adding a lateral extra-articular tenodesis (LET) to a hamstring graft cut graft rupture from 11% to 4% at 2 years in the STABILITY trial (Getgood et al., 2020), at the cost of slightly more pain in the first 3 to 6 months.

BTB (bone–patellar tendon–bone) graft

The central third of the patellar tendon is taken with a small bone block from the kneecap and the shin. The bone ends heal bone-to-bone in the tunnels.

Advantages: the longest track record, reliable fixation, and the lowest revision risk in large registries (Gifstad et al., 2014). Hamstrings are left untouched.

Trade-offs: front-of-knee and kneeling pain is the main drawback and can persist for years; a longer scar; slower early quadriceps recovery; and rare patellar fracture or tendon shortening. It is less suitable for people who kneel for work, prayer or floor-sitting.

Quadriceps tendon graft

A strip from the thick tendon above the kneecap is taken, with or without a small bone block.

What the evidence shows:

Failure rates similar to BTB and hamstring. A meta-analysis of 12 randomised trials found no difference in graft failure (RCT meta-analysis). Another found a lower failure risk than hamstring (Zhang et al., 2024).
Much less donor-site pain than BTB, with high-certainty evidence from 15 randomised trials (KSSTA meta-analysis).
Better hamstring strength than a hamstring graft, though quadriceps strength recovers more slowly at first.

Trade-offs: a technically demanding harvest, so outcomes depend on surgeon experience; and fewer long-term data, with most trials running 2 years.

Peroneus longus tendon graft

The peroneus longus runs down the outer side of the lower leg and helps turn the foot outward (eversion) and press the big toe down. It is harvested through a small incision above the ankle, leaving the knee's own muscles untouched. It has become popular in India and across Asia.

What the evidence shows:

Knee outcomes similar to hamstring. A meta-analysis of 23 studies and 925 patients found no difference in activity scores, knee stability, donor-site pain or graft failure (Hamstring vs PLT meta-analysis, 2020). A 2024 review of randomised trials reached the same conclusion (Eur J Orthop Surg Traumatol, 2024).
Larger, more predictable graft. Peroneus longus grafts are consistently thicker than hamstring grafts, with shorter harvest time (BMC meta-analysis).
Thigh muscle preserved. Hamstring patients showed significantly more loss of thigh muscle bulk (Rasul et al.).

The ankle question. Most studies report near-normal ankle function scores after harvest, because the neighbouring peroneus brevis compensates (Orthop Rev). However, objective testing in some studies has found weaker eversion and big-toe push-off and possible ankle instability (Eur J Orthop Surg Traumatol, 2024).

Who it suits: patients with thin hamstrings, those who want to avoid knee donor-site problems, and revision or multi-ligament reconstructions where knee grafts are limited.

Who should avoid it: people with flat feet, high-arched feet, ankle instability or previous ankle surgery on that side, and athletes whose sport relies heavily on push-off and cutting, such as sprinters, dancers and many elite pivoting athletes.

Limits of the evidence: most studies come from single centres in Asia, with follow-up of 5 years or less and no large registry data.

How the choice is made

Your situation	Grafts usually favoured
Under 20–25, returning to pivoting or contact sport	BTB or quadriceps tendon; hamstring with a lateral tenodesis if a hamstring graft is used
Open growth plates (adolescents)	Hamstring or soft-tissue quadriceps with growth-plate-sparing fixation
Kneel frequently for work, prayer or floor-sitting	Hamstring, quadriceps tendon or peroneus longus; avoid BTB
Thin hamstrings on MRI or at surgery	Quadriceps tendon or peroneus longus, or augmenting the hamstring graft
Sprinter, fast bowler or sport needing strong hamstrings	BTB or quadriceps tendon
Flat feet, ankle instability or push-off-dependent sport	Avoid peroneus longus
Revision ACL surgery	Depends on what was used before; quadriceps tendon and peroneus longus are useful options
Meniscus repair at the same time	Any graft; rehab follows the meniscus repair plan

Surgeon experience matters. A graft your surgeon uses often is likely to do better than a theoretically superior graft used rarely. This is especially true for quadriceps tendon harvest.

India-specific factors

Kneeling and floor-sitting are part of daily life for many patients, making BTB's kneeling pain more relevant here than in many Western countries.
Sport demands vary: fast bowling, fielding, kabaddi and badminton all load the knee differently. Discuss your specific sport.
Cost is broadly similar across the four autografts, since they use your own tissue. Donor (allograft) tissue usually costs more and has higher failure rates in young, active patients.

Rehabilitation and return to sport

The overall rehab plan is similar for all four grafts. What differs is the early focus:

Graft	Early rehab focus
Hamstring	Least early pain; protect and gradually rebuild hamstring strength, which may lag for a year or more
BTB	Manage front-of-knee pain; early, intensive quadriceps activation
Quadriceps tendon	Quadriceps strength dips early; dedicated quadriceps work usually closes the gap within months
Peroneus longus	Knee muscles spared; add ankle mobility, eversion strengthening and balance work

Return to sport: time and tests both matter. In the Delaware–Oslo cohort, each month that return to pivoting sport was delayed, up to 9 months, cut the reinjury rate by 51%. Patients who passed strength and hop tests before returning had far fewer reinjuries, and more symmetrical quadriceps strength lowered the risk further (Grindem et al., 2016).

We therefore plan return to pivoting sport for no earlier than 9 months, whichever graft is used, and only after you pass objective strength and hop testing. Our ACL surgery recovery guide and physical therapy protocol after ACL tear give the week-by-week detail.

Common myths

Myth	Fact
"Donor (allograft) tissue is better because there is no harvest pain."	Allografts have higher re-tear rates in young, active patients and are kept mainly for older patients, revisions and multi-ligament surgery.
"BTB is outdated."	It has the longest track record and the lowest revision rates in large registries.
"The newest graft is always the best."	Quadriceps and peroneus longus grafts are promising, but long-term data are shorter, and results depend on surgeon experience.
"Taking the peroneus longus has no effect on the ankle."	Most patients do very well, but some studies show measurable ankle weakness, so it is not for everyone.
"Once I pass 9 months, I'm safe."	Time alone is not enough; strength and hop tests must also be passed.

Questions to ask your surgeon

Given my age, sport and job, which graft do you recommend, and why?
Is my hamstring tendon likely to be big enough?
Is my foot and ankle suitable for a peroneus longus graft?
How many reconstructions with this graft do you perform each year?
Will I need a lateral tenodesis as well?
How will this graft affect kneeling, squatting and sitting cross-legged?
What tests must I pass before returning to my sport?

Frequently asked questions

Which ACL graft is best? None is best for everyone. BTB has the lowest revision rate in registries, quadriceps tendon offers similar results with less knee pain, hamstring gives the easiest early recovery, and peroneus longus avoids knee donor-site problems. The right choice depends on your age, sport, job and anatomy.

Which graft has the lowest re-tear rate? In large registries, BTB has a lower revision risk than hamstring. Quadriceps tendon appears similar to BTB in trials. Small hamstring grafts in young athletes carry the highest risk.

Is the peroneus longus graft safe? Short- to mid-term studies show knee results similar to hamstring and good ankle function in most patients. Some patients develop mild ankle weakness, and long-term data are still limited.

Which graft causes the least knee pain? Peroneus longus causes no pain at the knee harvest site, followed by hamstring and quadriceps tendon. BTB causes the most kneeling pain.

Will I be able to kneel after ACL surgery? Most patients can, especially with hamstring, quadriceps or peroneus longus grafts. Kneeling discomfort is most common after BTB.

When can I return to sport? No earlier than about 9 months for pivoting sports, and only after passing strength and hop tests, whatever graft is used.

What if my hamstring graft is too thin? Your surgeon may switch to a quadriceps or peroneus longus graft, add tissue to thicken it, or add a lateral tenodesis for extra stability.

The bottom line

All four autografts can give excellent results. BTB has the strongest long-term record but the most kneeling pain. Hamstring is easy on early recovery but riskier when small in young athletes. Quadriceps tendon matches BTB's reliability with far less knee pain. Peroneus longus spares the knee entirely and looks promising, but has shorter follow-up and potential ankle trade-offs. The best choice is the one tailored to your knee, sport and daily life, followed by at least 9 months of test-guided rehab.

To discuss which graft suits you, book a consultation with our sports orthopedic team at Sports Orthopedics Institute, HSR Layout, Bengaluru.

This article is for general information and does not replace a personal consultation with a qualified orthopedic surgeon.

References

Gifstad T, et al. Lower risk of revision with patellar tendon autografts compared with hamstring autografts: a registry study based on 45,998 primary ACL reconstructions in Scandinavia. Am J Sports Med. 2014;42(10):2319–2328.
Spragg L, et al. The effect of autologous hamstring graft diameter on the likelihood for failure of ACL reconstruction. Am J Sports Med. 2016.
Small-diameter hamstring grafts and reinjury risk: review. Am J Sports Med. 2019.
Getgood AMJ, et al. Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft ACL reconstruction: 2-year outcomes from the STABILITY study. Am J Sports Med. 2020.
Quadriceps versus hamstring and patellar tendon autografts for ACL reconstruction: systematic review and meta-analysis of randomised trials.
Zhang XF, et al. Efficacy and safety of quadriceps tendon autograft versus BPTB and hamstring autografts: a systematic review and meta-analysis. 2024.
Quadriceps tendon autograft versus BPTB: meta-analysis of 15 randomised trials with GRADE evidence. Knee Surg Sports Traumatol Arthrosc.
Peroneus longus tendon autograft has functional outcomes comparable to hamstring tendon autograft: systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2020;28(9):2941–2950.
Comparative effectiveness of peroneus longus versus hamstring autografts: systematic review and meta-analysis of RCTs. Eur J Orthop Surg Traumatol. 2024;34(5):2691–2699.
Peroneus longus versus hamstring autograft: short- and medium-term outcomes meta-analysis.
Rasul et al. Peroneus longus versus hamstring autograft in primary ACL reconstruction: systematic review and meta-analysis.
No difference in ankle morbidity 12 months after peroneus longus harvest. Orthop Rev.
Donor-site morbidity following ACL reconstruction using peroneus longus tendon autograft. Eur J Orthop Surg Traumatol. 2024;34:3171–3180.
Grindem H, et al. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware–Oslo ACL cohort study. Br J Sports Med. 2016;50(13):804–808.

Which ACL Graft Is Best for You? Four Options Compared