When you need surgery for a torn ACL, one of the biggest decisions is which graft (replacement ligament) to use. The three main options are:

1. Hamstring Tendon (HT) graft

2. Quadriceps Tendon (QT) graft

3. Patellar Tendon (Bone–Patellar Tendon–Bone, BPTB or PTB) graft

All three are strong and effective. The best choice depends on your body, sport, symptoms, and goals.

1. What each graft involves

Hamstring Tendon (HT)

• Uses two small tendons from the inner part of your thigh.

• Tendons are folded to form a strong graft.

Quadriceps Tendon (QT)

• Uses a strip of the tendon above the kneecap (from the quadriceps muscle).

• Usually harvested as a soft-tissue graft, sometimes with a small bone block.

Patellar Tendon (PTB/BPTB)

• Uses the central third of the tendon just below the kneecap, including small pieces of bone from the kneecap and shinbone (bone plugs).

• This graft has been used the longest and is sometimes called the classic “gold standard”.

2. How do they compare in strength?

All three grafts are stronger than the original ACL.

Hamstring

• Very strong

• Flexible

• Graft size can vary between people

Quadriceps Tendon

• Thick, robust graft

• Consistently large diameter

• Increasingly popular due to predictable size

Patellar Tendon (PTB)

• Strong with excellent bone-to-bone healing

• Historically used in high-level athletes

• Higher chance of front-of-knee discomfort

Overall: All grafts provide excellent knee stability. No graft is dramatically stronger in real-world outcomes.

3. Risk of re-tear (graft failure)

• Hamstring: Very good success rate; slightly higher re-tear risk in young, high-demand athletes if the graft is small.

• Quadriceps: Very good stability; may have slightly lower re-tear rates in young athletes in some studies.

• Patellar Tendon: Long-term data show excellent stability; re-tear rates similar to or sometimes slightly better than hamstring grafts.

Bottom line:
All three have low re-tear rates, especially when rehabilitation is followed properly.

4. Donor-site symptoms (how the harvest area feels after surgery)

Hamstring Tendon

Pros:

• Less pain at the front of the knee

• Small incision

Possible downsides:

• Hamstring muscle weakness can persist, especially noticeable in sprinters

• Occasional numbness inside the knee

Quadriceps Tendon

Pros:

• Lower long-term weakness than hamstring grafts

• Less kneecap pain compared to PTB

Possible downsides:

• Temporary quadriceps weakness (usually improves by 3–6 months)

• Soreness above the kneecap

Patellar Tendon (PTB)

Pros:

• Strong graft with excellent bone healing

• Preferred in certain high-level athletes (e.g., elite pivoting sports)

• Long history of use

Possible downsides:

• Higher risk of kneecap pain, especially when kneeling

• Slightly higher risk of patellar fracture or tendonitis (rare but possible)

• Some stiffness early in recovery

5. Return to sport

Most research shows similar return-to-sport timing for all three grafts.

However:

• PTB may offer the best stability for certain high-demand pivoting sports (football, rugby, basketball), but at the cost of more front-of-knee soreness.

• QT is becoming increasingly popular for athletes due to its size and stability, with less kneecap pain.

• HT is suitable for many athletes but may not be ideal for sprinters or athletes needing strong hamstrings.

6. Which graft is recommended for which type of patient?

Hamstring (HT) may be best if:

• You want less kneecap pain

• You don’t do heavy sprinting

• You prefer smaller incisions

Quadriceps Tendon (QT) may be best if:

• You are a young, high-demand athlete

• You want good stability with less kneecap pain

• Your hamstrings are small or weak

• You’re having a revision ACL surgery

Patellar Tendon (PTB) may be best if:

• You are a high-demand athlete in cutting/pivoting sports

• You want the graft with the longest history of use and excellent stability

• You don’t kneel frequently (jobs like flooring, mechanics, gardeners may prefer to avoid PTB)

7. Is recovery different between the graft types?

Rehabilitation is very similar across all grafts.
Differences include:

HT:

• Hamstring strengthening is introduced gradually.

QT:

• Focus on quadriceps activation early.

PTB:

• Some extra front-of-knee discomfort initially, especially with kneeling.

Time to running, cutting, and returning to sport is generally based on strength and control, not the graft type.

8. Which graft is “best”?

There is no single best graft for everyone.

The right choice depends on:

• Age

• Sport and activity level

• Anatomy (hamstring size, quadriceps strength)

• Whether it’s a first or revision surgery

• Your job (kneeling vs not kneeling)

• Surgeon expertise (one of the most important factors)

A well-chosen graft + a well-performed surgery + good rehabilitation = excellent outcomes.