Artificial Grafts for ACL Reconstruction
Artificial grafts should NOT be used for ACL reconstruction in young to middle-aged adults with high activity levels; autografts (bone-patellar tendon-bone or hamstring) are the standard of care and strongly recommended.
Primary Recommendation: Use Autograft, Not Artificial Graft
The American Academy of Orthopaedic Surgeons 2023 guidelines explicitly recommend autograft options—specifically bone-patellar tendon-bone (BPTB) or hamstring—for ACL reconstruction in skeletally mature patients 1. Notably absent from these comprehensive guidelines is any recommendation for artificial/synthetic grafts, which reflects the consensus that they are not appropriate for standard ACL reconstruction.
Why Artificial Grafts Have Failed
Historical experience with synthetic grafts demonstrates unacceptably high failure rates 2. Multiple synthetic materials have been attempted over decades—including Supramid®, Teflon®, Dacron®, carbon fiber, Gore-Tex®, and LARS®—but most have been characterized by high rates of failure 2.
The evidence is clear: artificial ligaments should NOT be considered for primary ACL reconstruction and should only be treated as an alternative in special cases, with the optimal synthetic graft material remaining controversial 2.
Recommended Graft Selection Algorithm for High-Activity Patients
First Choice: BPTB Autograft
For young, high-demand athletes where maximum stability and lowest graft failure risk are critical, BPTB autograft is preferred 3, 4.
- Reduces graft failure risk compared to other options 1, 5, 4
- Reduces infection risk 1, 4
- Provides superior stability for high-demand activities 4
- Trade-off: Higher risk of anterior/kneeling pain 1
Second Choice: Hamstring Autograft
Hamstring autograft is appropriate when avoiding anterior knee pain is critical 1, 3.
- Lower donor site morbidity 1, 3
- Reduced anterior and kneeling pain compared to BPTB 1
- Consider adding lateral extra-articular augmentation (ALL reconstruction or LET) to reduce re-rupture risk with hamstring grafts 5, 3
Allograft Consideration
Allograft shows moderate inferiority to autograft with higher failure rates and infection risk 6. In athletic populations, allograft is generally reserved for older individuals (typically over 45 years) or those with specific contraindications to autograft harvest 7.
Critical Clinical Pearls
Timing Matters
Early reconstruction within 3 months of injury is strongly recommended to reduce risk of additional cartilage and meniscal damage 3, 4. This represents a shift toward more aggressive early intervention 3.
Surgical Technique
Both single-bundle and double-bundle reconstruction techniques show equivalent outcomes, allowing surgeon preference to guide technique selection 1, 3, 4.
Return to Sport
Functional evaluation such as hop testing should be considered as one factor in determining return to sport clearance, using criterion-based rather than purely time-based progression 1, 3, 4.
Common Pitfalls to Avoid
Do not be tempted by the theoretical advantages of synthetic grafts (easier availability, no donor site morbidity, simplified surgery) as these are outweighed by unacceptably high failure rates in clinical practice 2.
Do not delay reconstruction beyond 3 months in young, active patients as this increases risk of secondary meniscal and cartilage injury 3, 4.
Do not use functional knee braces routinely after isolated primary ACL reconstruction as they confer no clinical benefit 1.