The Best Graft for ACL Reconstruction

The patellar tendon graft (PTG) has always been the gold standard for anterior cruciate ligament (ACL) reconstruction. Yet, most orthopedic surgeons prefer hamstring grafts for younger athletes and cadaver grafts for older patients.

PTGs allow for unrestricted rehabilitation and earlier return to sports than hamstring grafts. With the ACL reconstruction and rehabilitation process used at Shelbourne Knee Center, athletes return to sport in an average of about 4–6 months after surgery(1), compared to 12 months or more for hamstring grafts.

With hamstring and cadaver grafts, orthopedic surgeons want the knee to be stiff for stability. “Patients don’t want a stiff knee. They want a normal knee,” says K. Donald Shelbourne, MD, an orthopedic surgeon at Shelbourne Knee Center. “We feel using a PTG from the opposite knee gives patients the best chance of getting back to normal predictably.”

Solving Rehab Challenges

Rehabilitation after ACL reconstruction is more complicated when using PTGs compared to hamstring or cadaver grafts. When rehab is done properly, however, the results are far superior. By 2–3 months post-op, ACL reconstruction patients at Shelbourne Knee Center have nearly full extension and flexion:

  • Full extension: 98% of patients
  • Full flexion: 92%(2).

With hamstring and cadaver grafts, patients rarely achieve full range of motion or full strength, says Dr. Shelbourne. They’re left with knees that aren’t symmetric.

“The average orthopedic surgeon doesn’t have physical therapists working with him,” says Dr. Shelbourne. Seven physical therapists and one athletic trainer are part of the team at Shelbourne Knee Center, which has an on-site gym. The ACL rehab process includes pre-op and post-op rehab. Both focus on improving range of motion (ROM) before strengthening. The accelerated post-op rehab program also focuses on preventing swelling.

Achieving Quicker Return of ROM and Strength

While more orthopedic surgeons are starting to use PTGs, few are using contralateral PTGs. Dr. Shelbourne has been using contralateral PTGs since 1994, after observing the ease of rehab for his revision ACL reconstruction patients, where he had used a contralateral PTG.

Data from patients at Shelbourne Knee Center show quicker return of ROM and strength with contralateral PTGs. Patients also report that rehab is much easier.

In an early study comparing 434 contralateral patellar tendon graft and 228 ipsilateral graft patients, Dr. Shelbourne found:

  • No difference in knee extension between groups
  • Better knee flexion in the contralateral PTG group at 1,2, 4 and 8 weeks post-op
  • Better quadriceps strength in the contralateral PTG group at 1, 2 and 4 months post-op
  • No difference in KT1000 stability between groups(3)

More recent research evaluated strength and subjective scores for 279 contralateral patellar tendon grafts compared to 58 ipsilateral grafts(4). Quadriceps muscle strength compared with the pre-op normal knee was:

  • Ipsilateral ACL-reconstructed knee: 105%
  • Contralateral donor knee: 114%
  • Contralateral ACL-reconstructed knee: 116%

Mean side-to-side strength (ACL-reconstructed knee/opposite knee):

  • Contralateral group: 98.4%
  • Ipsilateral group: 92.9%.

Mean International Knee Documentation Committee (IKDC) Questionnaire total score for the ACL-reconstructed knee:

  • Contralateral group: 88.8
  • Ipsilateral group: 88.9

Developing Effective Rehab

Rehabilitation after ACL reconstruction with a contralateral PTG at Shelbourne Knee Center is split between the two legs. Goals of rehab for the ACL-reconstructed knee  are:

  • Prevent/control hemarthrosis
  • Return full symmetrical ROM
  • Provide appropriate stress to stimulate the graft to mature.

Rehab for the donor leg focuses on regaining strength.

A recent study by physical therapists at Shelbourne Knee Center showed high levels of ROM and quadriceps strength in both legs after rehab.

“A contralateral PTG is almost invincible,” says Dr. Shelbourne. “It’s been an overwhelming success at Shelbourne Knee Center.”

For more information about ACL reconstruction using a contralateral PTG, call 888-FIX-KNEE.


  1. Shelbourne KD, Urch SE. Primary anterior cruciate ligament reconstruction using the contralateral autogenous patellar tendon. Am J Sports Med. 2000;28:651-8
  2. Shelbourne KD, Beck MB, Gray T. Anterior Cruciate Ligament Reconstruction With Contralateral Autogenous Patellar Tendon Graft: Evaluation of Donor Site Strength and Subjective Results. Am J Sports Med. 2014;43:648-53.