Updated May 2026. Written by the Upwell Health Collective clinical team. Clinically reviewed May 2026. Next review due November 2026. For educational purposes only — not a substitute for individual clinical assessment or surgical advice.
At some point after an ACL diagnosis — usually around the second or third consultation, when the acute shock has settled and the reality of surgery is sinking in — every patient asks the same question: Which graft is best?
It is one of the most genuinely contested questions in orthopaedic sports medicine. Not because surgeons don't know enough. But because the honest answer is: it depends — and the things it depends on are specific, measurable, and worth understanding in detail before you walk into an operating theatre.
This is a deep-dive into the current state of graft selection evidence for ACL reconstruction in 2026. We cover the four main options — bone-patellar tendon-bone (BTB), hamstring tendon (HT), quadriceps tendon (QT), and allograft — what the best available research actually says about each, who each is best suited for, the emerging role of Lateral Extra-Articular Tenodesis (LET), and how to have an informed conversation with your surgeon about what's right for you.
This is not a simple article. ACL graft selection is not a simple topic. But it is navigable — and the athletes who understand their options consistently make better decisions and have better outcomes.
ACL reconstruction re-rupture rates are not small numbers. In young, high-risk athletes under 25 returning to cutting and pivoting sport, graft failure rates range from 7% to 25% depending on graft type, surgical augmentation, and rehabilitation quality (Wiggins et al.; STABILITY trial data, Getgood et al., 2020).
Re-rupture rates in adolescents and young athletes are meaningfully different between graft types. A systematic review of patients aged 19 and under found pooled failure rates of 8.5% for BTB autograft, 16.6% for hamstring autograft, and 25.5% for allograft — with allograft 3.87 times more likely to fail than autograft in this population (PMID: 34322650). In NCAA Division I athletes specifically, revision rates of 62% for allograft versus 0% for autograft have been reported in single-institution cohorts.
In a mixed-age, lower-activity population, the differences narrow considerably. But for the 18-year-old female footballer, the 22-year-old male rugby player, or the 16-year-old basketballer, graft choice is not an administrative detail. It is one of the most consequential decisions of their surgical journey.
At Upwell, our role is not to tell patients which graft to choose — that is a surgical decision made by the operating surgeon. Our role is to make sure every patient understands the landscape, can ask the right questions, and enters surgery with a plan that accounts for their specific risk profile.
BTB autograft — harvesting the central third of the patellar tendon with bone plugs at each end — was for decades considered the gold standard for ACL reconstruction, particularly in high-demand athletes. The bone plugs at each end allow direct bone-to-bone healing at the tibial and femoral tunnels, which is biologically more rapid and mechanically more secure than soft-tissue tunnel integration. This is one of BTB's most durable advantages.
The most recent meta-analysis of long-term (minimum 10-year) RCT data comparing BTB versus hamstring in primary ACLR found no significant differences in graft rupture or revision rates (RR 0.88; p=0.70), contralateral ACL rupture rates, Lysholm scores, or Tegner scores at a mean follow-up of 14.6 years (Gopinatth et al., Am J Sports Med, 2025). This is important context: at a decade-plus, both grafts perform similarly in the general adult population.
However, in high-risk subgroups — younger athletes, those with generalised joint laxity, high-grade pivot shift, or returning to high-demand pivoting sport — the BTB advantage becomes more clinically meaningful. A 2026 study comparing BTB versus hamstring outcomes stratified by risk profile found that in the high-risk group, BTB showed a significantly lower re-rupture rate (12.9% versus 35.7%; p=0.03). In the lower-risk group after matching, there was no significant difference (6.9% versus 5.2%; p=0.99).
The largest-scale data (national registries, systematic reviews of young athletes) consistently shows BTB as producing lower revision rates than hamstring in the under-25, high-activity population. A 2025 systematic review and meta-analysis of 4,810 athletes found no significant difference in overall RTS rates (83.3% BTB vs 77.6% HT) but noted that BTB shows consistently lower laxity outcomes across multiple studies (Connors et al., Orthop J Sports Med, 2025).
High-demand young athletes (particularly under 25) returning to cutting, pivoting, or contact sport. Athletes with generalised joint laxity or high-grade pre-operative pivot shift. Revision ACL when hamstring tendons have been previously harvested. Athletes who can tolerate the donor site morbidity and have no pre-existing anterior knee symptoms.
Hamstring autograft — typically the semitendinosus and gracilis tendons (the STG or ‘four-strand’ graft) — has been the most commonly used ACL graft in Australia and much of Europe for the past 20 years. It offers lower donor-site morbidity than BTB, no bone harvest from the extensor mechanism, and significantly less anterior knee pain post-operatively.
In the general adult athletic population across RCTs with long follow-up, hamstring and BTB produce clinically equivalent outcomes in terms of patient-reported function, return to sport, and graft survival (Gopinatth et al., 2025; Connors et al., 2025). The debate is not whether hamstring is a good graft — it clearly is — but whether it is the optimal graft in specific high-risk subgroups.
The key concern with hamstring is higher revision rates in younger, more active populations when used alone without LET augmentation. Large-scale observational studies and national registry data have reported meaningfully higher revision rates for HT compared to BTB in athletes under 25, particularly those with high-grade laxity or generalised joint hypermobility (Swedish ACL Register; NZACL data). This gap in revision risk is the primary driver behind the growing movement toward LET augmentation in young, high-risk HT reconstructions — which is addressed in the LET section below.
Graft diameter is a clinically important variable. Larger-diameter hamstring grafts (8mm or greater) consistently produce better outcomes than smaller grafts. Patients with naturally thinner hamstring tendons — which can be identified on pre-operative MRI — may be at higher re-rupture risk with HT and should prompt discussion of alternative graft selection or LET augmentation.
Adult athletes at lower to moderate re-injury risk. Older athletes (25+ returning to recreational or semi-elite sport). Athletes with anterior knee pain or patellofemoral pathology where BTB harvest is contraindicated. High-risk young athletes when combined with LET augmentation. Athletes with naturally robust hamstring tendons on pre-operative MRI.
Quadriceps tendon autograft is the fastest-growing option in ACL surgery globally. It has been available for decades but largely overlooked — partly due to perceived technical difficulty of harvest and partly due to insufficient long-term outcome data. Both of those barriers are now significantly reduced. QT is increasingly the preferred graft at leading ACL centres worldwide, and the evidence base for it has accelerated substantially since 2020.
The most comprehensive recent systematic review with meta-analysis of RCTs comparing QT versus HT and BTB (White et al., Knee Surgery Sports Traumatology Arthroscopy, 2026) found that QT autografts provide comparable clinical outcomes to both HT and BPTB for ACL reconstruction, with some evidence of lower donor-site morbidity. Meta-analysis of six RCTs found no significant differences in graft failure rates between QT, HT, and BTB. Tegner scores at 12 and 24 months were equivalent across groups.
QT has several biomechanical advantages that explain the enthusiasm for it among leading surgeons:
A 2025 donor-site morbidity comparison (Giusti et al., Advances in Orthopedics and Rehabilitation Therapy, 2025) found significant differences between QT and STG (hamstring) in total donor-site morbidity scores, numbness, and size of numbness — with QT producing lower overall morbidity on the validated ACL Donor-Site Morbidity Questionnaire.
The picture is not uniformly positive. A 2024 systematic review (Krumbach et al., Cureus, PMC11156480) found that QT autografts were associated with higher revision rates (4.7%) compared to PTB (1.5%) and HT (2.3%) grafts at 2-year follow-up in some registry-level analyses, with greater laxity and more positive pivot-shift tests. This contradicts other RCT-level evidence and likely reflects heterogeneity in surgical technique and centre experience during the learning curve for QT harvest. The most current, highest-quality evidence (the White et al. 2026 meta-analysis of RCTs) does not support the conclusion that QT produces inferior outcomes to HT or BTB.
The honest picture is that QT is producing equivalent outcomes in experienced hands, with lower donor-site morbidity — and the evidence base is still maturing. For centres with high QT volume and experienced surgeons, it is a legitimate first-line choice for primary ACLR. For centres with limited QT experience, the learning-curve consideration is real.
Increasingly, many leading surgeons consider QT their first choice for primary ACLR in young, athletic patients at centres with high QT surgical volume. Athletes for whom anterior knee pain would be particularly impactful (anterior knee pain history, workers who kneel). Patients where graft size matters — smaller patients with potentially thin hamstring tendons. Revision settings when both hamstring and patellar tendon have been previously used.
Allograft — cadaveric tissue, processed and sterilised, from a tissue bank — is the outlier in the graft debate. It has genuine clinical roles, but the evidence for its use in young, active athletes is among the clearest and most alarming in all of ACL surgery.
The evidence against allograft in young, active patients is not subtle. A systematic review of young and active patients (mean age 21.7 years) found pooled failure prevalence of 9.6% for autografts and 25.0% for allografts — autograft 64% less likely to fail (RR 0.36; 95% CI 0.24–0.53; p less than 0.0001) (Failed ACLR: Autograft vs. Allograft in Young Patients, PMC4482307). In a cohort of NCAA Division I athletes, revision ACLR rates were 62% for allograft versus 0% for autograft in the same cohort.
A systematic review specific to patients aged 19 and under found pooled failure rates of 8.5% (BTB autograft), 16.6% (hamstring autograft), and 25.5% (allograft) — with allograft 3.87 times more likely to fail than autograft (OR 3.87; 95% CI 2.24–6.69) (PMID 34322650).
The biology explains this: allograft tissue must undergo a process of incorporation, revascularisation, and remodelling in the host knee that takes longer and is less complete than autograft. The graft is also processed and sterilised using techniques (irradiation, freeze-drying) that can degrade mechanical properties. Younger, more active patients place higher loads on a graft that is biologically behind where an autograft of equivalent age would be at the same timepoint.
In older (over 40) lower-activity patients, allograft outcomes converge toward autograft. The age-dependent failure rate gradient is steep and well-documented. Allograft fails at significantly greater rates in patients under 34 years of age (ScienceDirect, 2023). Above 40, the difference largely disappears.
No discussion of ACL graft selection in 2026 is complete without addressing LET. The STABILITY trial — the most important piece of ACL surgical evidence published this decade — has fundamentally changed the conversation around graft choice in high-risk young athletes.
The STABILITY Study (Getgood et al., Am J Sports Med, 2020) was a pragmatic, multicentre randomised clinical trial of 624 patients aged 14–25 years with an ACL-deficient knee. All patients had at least two of the following: Grade 2 pivot shift or greater; returning to high-risk pivoting sport; generalised ligamentous laxity. Patients were randomised to standard hamstring ACLR versus ACLR plus Modified Lemaire LET (a strip of iliotibial band).
Results at 2 years: adding LET reduced graft failure or persistent rotatory instability from 41% to 25% — a 40% relative risk reduction. The addition of LET did not significantly increase overall adverse events, minor surgical events, or overall re-operation rates. The specific concern that LET would restrict knee range of motion or produce excessive stiffness did not materialise in the trial data.
Subsequent work from the STABILITY experience identified the strongest predictors of graft failure in the trial population: not receiving LET, younger age, generalised ligamentous laxity, smaller graft diameter, and high-grade pre-operative pivot shift. This provides a clear, evidence-based risk stratification framework that surgeons can use pre-operatively to identify which patients most need LET augmentation.
More recent data (Mioc et al., J Exp Orthop, 2025) specifically in under-20 athletes undergoing hamstring ACLR with concurrent LET found low graft failure rates and good functional outcomes at mean follow-up of almost 50 months — supporting LET as a durable augmentation strategy in this highest-risk population.
Following the STABILITY trial and the growing literature base, the clearest indications for LET discussion with your surgeon include:
LET is most established when added to hamstring autograft reconstruction — it specifically addresses the rotatory stability limitation that hamstring grafts, via their intra-articular placement, are less effective at controlling. LET is an extra-articular procedure that directly restrains internal tibial rotation — the motion most associated with ACL failure under pivoting loads.
It is important to note that LET augments hamstring autograft reconstruction — it does not make allograft an appropriate choice in young athletes. The evidence base for LET is specifically built on hamstring autograft. LET + allograft in young athletes is not supported by the current evidence base and should not be considered equivalent to ACLR + LET with autograft.
Graft choice has direct implications for rehabilitation design. This is something every physiotherapist and exercise physiologist involved in ACL rehabilitation needs to understand explicitly.
BTB patients typically present with significant anterior knee pain and extensor mechanism disruption in the early post-operative period. The primary rehabilitation focus in Phase 1 is aggressive swelling management, immediate full extension restoration (the Upwell obsession), and graduated quad activation. The harvest site requires specific desensitisation and patellar mobilisation work that HT patients don't need.
Hamstring patients face a specific strength deficit that is both direct (harvested tissue) and neuromuscular (altered afferent signalling from the hamstring complex). Rate of force development in the hamstring is severely compromised in the early and mid phases. BFR training is particularly valuable for HT patients in early rehabilitation to stimulate hypertrophy without loading the graft. Eccentric loading, flywheel training, and Nordic hamstring progressions are essential components of the force system rebuild. The hamstring's role as a dynamic ACL co-protector (via its posterior shear force on the tibia) means that its deficit has biomechanical implications beyond just strength numbers.
QT patients present differently again. The quadriceps itself is not dramatically weakened by the harvest of a partial-thickness strip of the tendon, but the inhibitory response post-operatively (arthrogenic muscle inhibition) affects all ACLR patients regardless of graft. QT patients generally have less anterior knee pain than BTB patients and less hamstring deficit than HT patients — meaning the rehabilitation can progress some components faster. However, the nervous system deficits, movement retraining requirements, and psychological components of rehabilitation are identical regardless of graft type.
Patients who have received LET augmentation have an additional extra-articular procedure to account for. Early mobilisation principles still apply — immobilisation is not indicated — but the iliotibial band harvest site and the lateral knee sutures require attention. Some surgeons apply a brief period of protected range of motion in the immediate post-operative period. The overall rehabilitation trajectory is not dramatically different, but the early Phase 1 period needs to be managed with awareness of the additional surgical site.
Revision ACL reconstruction — when the first graft has failed and needs to be replaced — introduces additional complexity to graft selection. The principles are:
Armed with this evidence, here are the most important questions to bring to your pre-operative surgical consultation:
1. Which graft are you planning, and why for me specifically? The answer should be personalised — referencing your age, activity level, sport, laxity profile, and anatomical considerations. "That's what I use for everyone" is not a satisfactory answer.
2. What is your re-rupture rate with this graft in my age group and activity level? Surgeons with high ACL volume should be able to share outcome data. National registry data is also publicly available as a benchmark.
3. Am I a candidate for LET augmentation? If you are under 25, returning to high-demand sport, and have any laxity, this question is mandatory. The STABILITY trial criteria are: Grade 2 pivot shift or greater, high-risk pivoting sport return, and generalised ligamentous laxity — any two of three qualify.
4. What is my graft diameter on pre-op MRI, and does that affect the plan? For hamstring patients particularly, a predicted graft diameter below 8mm is a meaningful risk factor that should prompt discussion of alternative graft or LET augmentation.
5. What are the donor-site implications of this graft for my specific job and sport? A tradesperson who kneels daily has different donor-site considerations than an office worker. A footballer has different concerns than a golfer.
6. If my graft fails, what is the revision plan? Understanding the downstream implications of graft choice for potential future revision surgery is sensible planning, not pessimism.
Upwell's ACL rehabilitation programme is individually tailored to graft type, surgical augmentation, and the patient's specific risk profile. Our collaboration with Melbourne's leading ACL surgeons means we receive detailed operative notes, graft diameter, fixation method, and any augmentation procedures before the patient's first post-operative appointment.
Our physiotherapy team manages the graft-specific Phase 1 requirements: BTB anterior knee pain and extension restoration, HT hamstring protection and graduated hamstring loading, QT quadriceps response monitoring, and LET lateral knee site management.
Our exercise physiology team designs the force system rebuild around graft-specific deficit profiles — aggressive BFR and eccentric hamstring loading for HT patients, targeted quad activation and anterior knee desensitisation for BTB patients, and the validated MRSS 2.0 return-to-sport criteria applied regardless of graft type.
VALD force plate assessment allows us to identify and quantify the graft-side deficit at any timepoint and monitor its resolution with objective, bilateral data — not clinical impression.
If you are pre-operative and navigating the graft decision, we are happy to talk through the evidence with you before surgery. If you are post-operative, our programme accounts for your specific graft from the first session. Contact our team or book online.
No framework replaces an individualised surgical consultation. But as a general guide, here is how the current evidence maps onto common patient profiles:
High-demand athlete, under 25, returning to cutting/pivoting sport, generalised laxity or high-grade pivot shift: BTB autograft, OR hamstring autograft + LET. Allograft is contraindicated. QT is a legitimate option at experienced centres.
Recreational or semi-elite athlete, 25–40, returning to moderate-demand sport: Hamstring or BTB autograft. QT is a legitimate option. Graft selection can more freely reflect surgeon preference and patient donor-site concerns.
Athlete over 40, returning to recreational sport: Hamstring autograft, QT, or allograft are all reasonable. Donor-site morbidity considerations become relatively more important.
Revision ACL reconstruction, prior hamstring harvest: BTB or QT autograft. Allograft becomes more appropriate if autograft supply is genuinely limited.
Female athlete, under 22, high-demand pivoting sport (AFLW, netball, basketball): BTB or hamstring + LET. QT at experienced centres. The ACL gap evidence strongly supports LET discussion in this population.
ACL graft selection is one of the most genuinely contested decisions in sports medicine. The good news is that the evidence is now detailed enough to make that decision systematically rather than by surgeon habit or patient preference alone.
The key principles from 2026's best evidence:
Know your risk profile. Ask the right questions. Choose your surgeon based on their volume and outcomes with your planned graft type, not just reputation. And build the most comprehensive rehabilitation programme around that graft that the evidence supports.
This article is for educational purposes only and does not substitute for individual surgical or clinical assessment. Graft selection decisions should be made in consultation with a qualified orthopaedic surgeon who has reviewed your specific anatomy, imaging, and clinical presentation. Information last reviewed May 2026.