Episode 289 | Why Your Surgeon’s Favorite Graft Might Not Be Right For Your ACL Surgery

What is up, team? And welcome back to another episode on the ACL Athlete Podcast. If you have talked to more than one person about ACL surgery, you probably heard a line like this. This was actually something that I heard from an athlete this past week, and when we were talking through graft types, they were like, “Oh isn’t it the best graft is the one your surgeon is good at?”

And maybe this is something that your physical therapist said; maybe it is something that you saw on a Facebook group or Reddit or whatever forum or place where people comment. You will also hear opinions, especially if people are like, “Which is the best graft?” Be careful going down that rabbit hole, especially on forums, because everyone will either have a very strong opinion about their graft one way or another.

The idea that the “best graft” is simply the graft your surgeon performs most often is not necessarily wrong, but it is incomplete. A surgeon’s experience and volume with a particular graft absolutely matter, but that is only one part of the decision. The bigger question is whether that graft is actually appropriate for your individual situation, because every ACL injury, athlete, body, goal, and recovery is different. Comparing grafts based solely on someone else’s experience is difficult because you are rarely comparing equivalent circumstances. An allograft in one person may have very different implications from a quad tendon graft in another person with a completely different injury profile, activity level, age, and goals.

The problem is that people are becoming more educated about ACL surgery, which is generally a good thing, but that also means they are encountering increasingly strong opinions about graft selection. You can find people online insisting that one graft is superior, while someone else will insist that another graft is the obvious choice. The same thing happens when people hear that they should choose the graft their surgeon is “best at.” Surgeon expertise matters, but it should not automatically determine the answer before the patient’s individual needs have even been evaluated. The graft should be selected for the person first, and then the surgeon’s expertise with that graft should become the next filter.

Graft choice is important, but it is not the only major decision in the ACL process. From my perspective, the rehab provider is one of the most important decisions you will make because that person will be with you throughout the recovery and will guide the work that happens after surgery. The surgeon is obviously important, and graft selection matters, but the quality and structure of rehabilitation can have a tremendous influence on what happens afterward. There are excellent surgeons working with different graft types, and experience across hundreds of surgeons and many ACL cases makes it clear that there is no single graft that automatically produces the best outcome for every person. For most ACL reconstructions, the major graft categories are patellar tendon, quadriceps tendon, hamstring, and allograft, with other approaches such as BEAR and ACL repair continuing to develop.

There is also a reason the advice about choosing what the surgeon does best exists in the first place. Most surgeons develop particular expertise during residency and fellowship, often becoming especially experienced with one or perhaps two graft techniques. Their mentors, training environment, and the number of procedures they perform all shape their clinical practice. A surgeon who has spent years becoming highly skilled with a particular graft is naturally going to have confidence in that technique and may recommend it frequently. That is not necessarily dishonesty or poor care; it is a natural consequence of specialization and experience.

The difficulty comes when the surgeon’s expertise becomes the first and only filter. A surgeon may be excellent at a particular procedure and still not be the ideal person for a patient whose individual circumstances point toward another graft. The surgeon may genuinely believe their preferred technique is the best option, but their recommendation is still being made through the lens of their training and experience. Every profession has these biases, including physical therapy, where clinicians can sometimes be overly hesitant to refer someone for additional medical intervention because they naturally want to avoid surgery. Recognizing these biases is not about attacking a profession; it is about understanding that every expert sees a problem through the lens of their training.

The patient is also in a uniquely vulnerable position during a surgical consultation. You may be frightened, overwhelmed, and desperate for someone to tell you exactly what to do. Across from you is a confident medical expert who has spent years training and who appears to have a clear answer. It is easy to simply nod along, particularly when the discussion is full of unfamiliar medical terminology, and you are trying to process the fact that your season, sport, lifestyle, or identity as an active person has suddenly been disrupted. I experienced that myself with my first ACL injury as a teenager and again during my second ACL injury in college. When fear and urgency meet expertise, it is very easy for a recommendation to feel like the entire decision when it is actually only one part of it.

That is why the decision should be viewed through two filters. The first filter is what graft is right for you specifically. The second filter is whether the surgeon is actually skilled and experienced with that specific graft. The order matters because you should not simply fit yourself into the surgeon’s preferred procedure. You need to identify what makes sense for your body, your goals, your history, and your circumstances first, and then find the right person to perform that procedure.

In many consultations, the second filter is discussed far more than the first. You may hear about how many procedures the surgeon performs, how confident they are with a particular graft, and what their outcomes look like. What is often missing is a detailed conversation about why that particular graft makes sense for you. The best consultations should involve more than simply telling you what the surgeon prefers. They should involve questions about your life, goals, activities, previous injuries, and the demands you are going to place on the knee after surgery. Good surgeons can still give a strong recommendation while explaining the reasoning behind it and, when appropriate, discussing alternatives.

The first filter should therefore focus on the individual. Age is one major consideration because the risk-benefit profile of different grafts can change depending on the patient’s age and activity level. Younger, highly active athletes returning to cutting and pivoting sports generally have different graft considerations than older individuals returning to lower-demand activities. Allografts, for example, have been associated with higher failure rates in younger and more active populations compared with autografts. That does not mean an allograft is automatically wrong for every younger person or automatically right for every older person; it means age and activity level need to be part of the discussion.

Your goals are equally important. The demands placed on the knee by a soccer player who needs to repeatedly cut and pivot are very different from those of someone whose primary goal is hiking, recreational skiing, or strength training. Even two people of the same age with the same ACL injury may reasonably have different graft considerations because they are asking their knees to do different things. Sport, position, activities, and the level at which you want to participate all need to be discussed. The graft decision should be based not only on what you want to do immediately after rehab, but also on what you want your knee to tolerate for years afterward.

Previous injury history is another major factor. That includes previous ACL reconstruction, meniscus injury, cartilage problems, patellofemoral pain, or other problems involving either knee. It also includes the health of the tissue that would be harvested for an autograft. A person with a history of significant patellar tendon problems, for example, may require a different conversation about using a patellar tendon graft. Similarly, previous hamstring or quadriceps tendon issues may influence whether those tissues are appropriate donor sites. The question is not simply whether a graft works in general, but whether taking that particular tissue from that particular person makes sense given everything that has happened before.

Other biological considerations can matter as well. Hypermobile individuals and people with connective tissue disorders may have different considerations because of the way their tissues respond to injury and loading. Someone who sustains a disproportionately severe injury from what appears to be a relatively minor mechanism may require additional thought around graft selection and overall surgical planning. These cases are context-dependent and cannot be reduced to one universal rule. The important point is that the patient’s history should actually be evaluated rather than assuming the surgeon’s usual graft is automatically appropriate.

Occupation and hobbies are also commonly overlooked. The knee is not only used for sport. Someone may spend their workday kneeling, squatting, climbing, crawling, or repeatedly getting up and down from the floor. The same can be true for hobbies such as gardening, yoga, or other activities that involve deep knee flexion or prolonged kneeling. A person who loves yoga, for example, may have very different concerns about donor-site symptoms from someone who rarely kneels. These details may seem minor during a surgical consultation, but they can become extremely important once the patient is trying to return to the life they actually care about.

Autograft harvest can produce donor-site symptoms, and those symptoms need to be considered in the context of what the person wants to do. This does not mean that donor-site discomfort will necessarily persist forever or that a particular graft should automatically be avoided. Rehabilitation can influence how the donor site recovers and how symptoms are managed. But if someone has a lifestyle that places heavy demands on the area from which the graft would be taken, that should be part of the decision. The goal is not simply to reconstruct the ACL; it is to create a knee that can function well for the person’s entire life.

Skeletal maturity is another major consideration, particularly for younger athletes. If an athlete still has open growth plates, that can change the surgical options and may override some of the other considerations. Certain techniques may not be appropriate because of the risk of affecting growth plates, which means the surgeon may need to consider alternative grafts or physeal-sparing approaches. ACL injuries are occurring in increasingly young athletes, including children around 10 years old, which makes this issue particularly important. Age in this context is not merely a number; skeletal maturity can fundamentally alter what procedures are available.

Those five factors—age, goals and sport or activity demands, previous injury history, occupation and hobbies, and skeletal maturity—are not the only possible variables. They are simply some of the heavier-weight factors that can meaningfully change the graft decision for many people. The goal is not to overwhelm someone with fifteen or twenty variables that they cannot possibly process during an already stressful consultation. It is to focus attention on the factors most likely to change the recommendation. Once those factors are understood, the surgeon’s experience with the graft becomes an important second filter.

This framework also applies whether someone is facing a first ACL reconstruction, a second or third reconstruction, or a more complicated combined procedure. Revision ACL cases can become more nuanced because previous grafts may already have been used, tunnels may have been created, bone stock may be different, and the available graft options may be narrower. Additional procedures, such as an LET or treatment involving other ligaments, can also change the equation. The exact details of revision surgery deserve their own discussion, but the same two filters still apply: determine what is appropriate for the individual and then make sure the surgeon has the appropriate expertise to execute it.

The practical questions you bring into the consultation are therefore extremely important. Instead of simply asking why the surgeon likes a certain graft, ask, “Why is this graft right for me specifically?” That forces the conversation away from the surgeon’s general preference and toward your age, goals, injury history, activities, and individual circumstances.

Another useful question is, “What would you have recommended if I were not the kind of case you usually see?” That can reveal whether the surgeon is considering alternatives or whether their recommendation is primarily driven by the procedure they most commonly perform. These questions are not intended to challenge the surgeon unnecessarily; they are designed to make sure you understand the reasoning behind the recommendation.

It is also important to recognize that sometimes the answer really will be the graft the surgeon prefers and performs most often. The point is not to reject that recommendation simply because the surgeon has a specialty. If the graft is appropriate for you and the surgeon has extensive experience with it, that can be an excellent combination. The problem occurs when the surgeon’s expertise becomes the reason the graft is selected instead of being the second part of a patient-specific decision. You want both sides of the equation: the right graft for you and the right surgeon for that graft.

The same principle applies when circumstances limit your options. Someone living in a rural area may have only one surgeon who accepts their insurance, and that surgeon may primarily perform one graft type. In some cases, that may still be a perfectly reasonable decision once all the circumstances are considered. In other situations, getting another opinion may be worth the inconvenience, cost, delay, or additional scheduling effort. ACL reconstruction is a permanent intervention that can influence the trajectory of your activity and function for years, so it deserves thoughtful decision-making rather than simply accepting the first available answer.

At the same time, if you already had surgery and now regret your graft choice, that does not mean you made a stupid or careless decision. Most people are making the best decision they can with the information, expertise, insurance, time, and resources available to them. You may have been overwhelmed during the consultation or simply trusted the recommendation of the person you believed knew what was best. That is understandable. The important thing now is to determine what is actually causing your current difficulties rather than assuming the graft itself is automatically the problem.

If you are struggling after ACL reconstruction, the next step is to audit the situation. Is the problem related to rehabilitation? Is it biological? Is there a strength deficit, inadequate programming, poor load management, a range-of-motion issue, or another factor that has not been addressed? The graft type may be relevant, but it is only one piece of the overall recovery. A poor outcome does not automatically mean that choosing a different graft would have solved everything.

There is also a danger in information overload. With podcasts, Instagram, YouTube, Reddit, Facebook groups, research reviews, and AI tools, people now have more ACL information available than ever before. That access can be incredibly valuable, but more information does not automatically produce a better decision. People can become overwhelmed by conflicting opinions and start treating every anecdote as if it were evidence that applies directly to their own situation. The goal should be education that helps you ask better questions, not endless consumption of information that leaves you less certain than when you started.

Online communities can be useful for learning what questions to ask and understanding what other people have experienced, but individual stories should not become the basis for determining what graft is right for you. Someone else’s recovery occurred inside an entirely different biological, surgical, rehabilitation, and lifestyle context. Instead, look for qualified professionals who can evaluate your specific situation, explain their reasoning, discuss the available options, and demonstrate meaningful experience with the procedures they perform. You want someone who can understand your context rather than simply placing you into the category they see most often.

Ultimately, there is no honest universal answer to the question, “What is the best ACL graft?” The better question is, “What is the best graft for this person, and who is the best surgeon to perform it?” The surgeon’s experience matters enormously, but it should come after the patient-specific decision rather than replacing it. If you are preparing for surgery, use the two-filter framework to make sure both sides of that decision are being addressed. Your goal is not to find the graft that is universally best; it is to find the option that makes the most sense for your individual circumstances and then have it performed by someone who is highly skilled at that procedure.

If you are already on the other side of surgery, the same framework can still help you understand your situation. You do not need to spend your recovery wishing you had made a different decision without first determining what is actually limiting you. There may still be meaningful opportunities to improve strength, function, load tolerance, confidence, or other aspects of your recovery. The most important thing is to assess the actual problem in front of you and build a plan around that rather than getting trapped in hindsight.

This is a complicated decision, but it does not need to be an impossible one. Start with yourself: your age, your goals, your sport and activities, your previous injury history, your work and hobbies, and your skeletal maturity when relevant. Then ask whether the surgeon you are considering has the appropriate experience and volume with the graft that best fits your situation. That is a much more useful framework than simply accepting the phrase that “the best graft is the one your surgeon is good at.” The surgeon’s expertise matters, but the person receiving the graft has to remain at the center of the decision.

If you had a graft that you potentially regret or wish you did differently, I hear you, and I don’t want you to feel like that was a poor decision. I think that was something that I think was intentional for the way it played out, and just know that there is something that can be done to improve this. We just have to audit and see is it a rehab thing, is it a biology thing, and then make a plan from there.

But if you’re someone who is deciding on the graft, I really hope you use this. If you do, please send me a message, or if you have any thoughts about this episode, I would really appreciate it. This is your host, Ravi Patel, signing off.