One of the most common questions I get in clinic is which graft to choose for an ACL reconstruction. Thanks to the increasing use of AI tools, many of my patients come in much more informed than they used to. The question of ACL graft choice has been debated for over 25 years, and every month new studies are published comparing one graft type to another or assessing outcomes among different surgical techniques. The fact that this discussion continues is a clear sign that there’s still no single right answer.
A recent systematic review in the American Journal of Sports Medicine analyzed multiple studies to identify risk factors for developing arthritis after ACL reconstruction. Six factors were found to be associated with higher arthritis risk: older age, male sex, higher body mass index, bone–patellar tendon–bone graft, meniscectomy, and a longer time between injury and surgery.
Some of these risk factors are beyond our control—we can’t change our age at injury, sex, body weight at the time, or whether a meniscal tear occurred with the ACL injury. However, we can take proactive steps in choosing the type of graft and surgical timing. Selecting a graft with lower donor site morbidity, such as a hamstring or quadriceps tendon, and having surgery relatively soon after injury may help reduce the risk of developing arthritis later on.
