**3.1 Autografts**

Contrary to a common belief, the bone-patellar-tendon-bone (BPTB) remains the most frequently used autograft (Shelton and Fagan, 2011), but hamstring and quadriceps tendon grafts are common alternative.


Table 1. This table summarizes the factors to be considered in ACL autograft selection (from Shelton and Fagan, 2011).

All three graft types exhibit strength values above 2,000 N.

**3.1.1** BPTB autograft, which has two bone plugs at each of its extremities, affords the most secure fixation, a low failure rate and high rate of patient satisfaction. This is the graft of choice among team physicians dealing with high level professional athletes (Pandarinath et al., 2011). However, it is associated with increased anterior knee pain and numbness with a greater incidence of extension loss and long term osteoarthritis of the knee. Residual anterior knee pain can be decreased by filling the bony defects of the harvesting sites, and numbness can be prevented by saving the infrapatellar branch of the saphenous nerve during harvesting.

**3.1.2** Hamstring grafts are associated with less harvesting morbidity than BPTB, however, they exhibit a slighter degree of laxity, especially in females. Their harvesting weakens flexion strength of the knee and may account in the reported incidence of graft failure. They are usually fashioned in a quadrupled stranded graft using both gracilis and semitendinosus tendons.

**3.1.3** Quadriceps tendon has a low incidence of anterior knee pain and almost no residual numbness. It can be fashioned with or without bone plug. After harvesting, quadriceps deficit is temporary. Clinical outcome is excellent with residual laxity similar to BTB both in males and females, without extension deficit. For many, this is the graft of choice for ACL revision or posterior cruciate ligament reconstruction.

Most studies which have reported results of ACL reconstruction show no significant difference in residual anterior laxity, functional results and International Knee Documentation Committee (IKDC) scores regardless the autograft which is used (Aune et al., 2001; Beynnon et al., 2002; Freedman et al., 2003; Maletis et al., 2007; Yunes et al., 2001)
