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Anterior cruciate ligament (ACL) reconstruction is one of the most studied surgeries performed within any surgical specialty. The focus of much of this research has been related to graft selection and its impact on clinical outcomes. Favorable characteristics of graft options for ACL reconstruction include those that have similar structural and biomechanical characteristics of the native ligament, allow for secure fixation, permit rapid biologic incorporation, and have limited donor site morbidity. Ideally, the graft selected should allow for early, active rehabilitation and maintain its biomechanical properties and strength until full graft incorporation and biologic maturation. Ultimately, any graft construct should approximate or exceed the physical and mechanical properties of the native ACL.

There are many graft sources available to the surgeon, and these can be broadly categorized into autografts and allografts. Autologous grafts can be harvested from the ipsilateral or contralateral patellar tendon, the semitendonosis and gracilis tendons, or from the quadriceps tendon with or without a bone plug. Allografts typically used for ACL reconstruction include cadaveric forms of these same types of autologous grafts as well as tibialis anterior and Achilles tendon grafts.

Many surgeons prefer a certain graft based on their training and observed clinical outcomes in their practice. Regardless of personal preference, however, each graft has relative advantages and disadvantages and should be appropriately and individually considered based on patient age, size, activity level, pain tolerance, and return to sport goals. The goal of this chapter is to review the peer reviewed literature on ACL graft sources and allow the surgeon to make an educated decision with his or her patients as to the appropriate graft for each individual patient.

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