How do pre-existing conditions influence ACL graft choice?

In my practice, there are some knee conditions that are “deal-breakers” when considering particular grafts for individual patients.


  • If a patient has signs of patellar chondromalacia (softening of the cartilage at the kneecap) or patellar arthritis, then BTB autograft is contraindicated.
  • If a patient already has anterior knee pain (pain at the front of their knee or behind the patella) then BTB autograft should be avoided.  This pain could be exacerbated, long-term and/or permanent if BTB is used in a patient who already has discomfort at the front of the knee.  
  • If a patient has inherent pathologies of the patellar tendon, such as Osgood-Schlatters disease or Shindig-Larsen-Johansson syndrome, then BTB autograft may be unsuitable,
  • If a patient has evidence of patellar maltracking or malalignment, then BTB autograft is not ideal.


  • Patients with chronic hamstring tendinitis or a history of hamstring injuries may prefer to avoid hamstring (HS) autografts. 
  • Also, in our experience, small-statured females or obese individuals sometimes have small hamstrings in terms of diameter and the resulting small size (< 7 mm) may increase the risk of re-rupture. 
  • If a patient has had previous surgery around the insertion site of the hamstring tendons (i.e., medial tibial plateau fracture, previous ACL reconstruction, tibial osteotomy, etc) the anatomy can be scarred, making dissection of the hamstring tendons difficulty.
  • If a patient has a MCL (medial collateral ligament) sprain, depending on the degree of the sprain, we will refrain from taking the hamstring, since it is a stabilizing structure at the medial side of the knee.


Some folks have inherently “lax” or “loose” ligaments or joints, where even their uninjured knee “behaves” as if the ACL is torn or loose.  In this population of people, I find it preferable to consider a graft that is more stiff (like BTB autograft) and/or to consider an extra-articular augmentation procedure (Anterolateral Ligament Reconstruction/Augmentation) to confer greater stability to the knee and share the excessive forces that the ACL graft will experience.