ACL Reconstruction with Hamstring Tendon Graft
A torn ACL is not repaired, it is replaced. The ligament does not heal back together, so reconstruction means building a new one from tendon taken elsewhere, and the hamstring tendons are among the most common sources.
Graft choice is one of the genuine decisions in ACL surgery, and hamstring and patellar tendon grafts each have a case. Steven Struhl, MD is board certified in orthopedic surgery and separately in sports medicine and arthroscopic surgery, completed his sports medicine fellowship at Penn State University, and has performed more than 5,000 arthroscopic procedures since entering practice in 1991.
How a Hamstring ACL Graft Is Made
Two tendons from the inner hamstring, the semitendinosus and sometimes the gracilis, are harvested through a small incision below the knee. They are folded and bundled, usually into four strands, which produces a graft stronger than the native ACL it replaces.
- Small Harvest Incision: the tendons are taken through an opening a few centimeters long.
- Quadrupled Construction: folding the strands multiplies the tensile strength considerably.
- Tunnel Placement: bone tunnels are drilled to reproduce the native ligament’s position.
- Fixation: the graft is secured with buttons, screws, or a combination, depending on the case.
Tunnel placement is the part that determines whether the reconstruction behaves like a real ACL. A technically strong graft in the wrong position fails, which is the most common cause of the revision surgery that follows a failed reconstruction.
Hamstring Graft Versus Patellar Tendon Graft
Both work. The differences are real and they matter differently to different patients.
- Less Kneeling Pain: hamstring grafts avoid the anterior knee pain associated with patellar harvest.
- Smaller Incision: the harvest site is less visible and less painful early.
- Slower Incorporation: soft tissue heals into bone more slowly than the bone plugs of a patellar graft.
- Hamstring Weakness: some patients retain a measurable deep flexion strength deficit.
Patients who kneel for work or sport frequently prefer hamstring grafts for that reason alone. Athletes in sports demanding maximum hamstring output sometimes prefer the alternative.
ACL Reconstruction Recovery Timeline
- Weeks One To Two: controlling swelling and restoring full extension, which matters most.
- Weeks Two To Twelve: progressive motion and quadriceps strengthening.
- Months Three To Six: running, agility work, and sport specific movement patterns.
- Months Nine To Twelve: return to cutting and pivoting sport, guided by testing rather than the date.
Return to sport at nine to twelve months rather than six reflects a genuine change in practice, driven by evidence that earlier returns carry considerably higher re-injury rates.
What Determines the Result
The graft is one variable among several, and it is not the one most patients should focus on. Full extension in the first two weeks, quadriceps strength that matches the other leg before return to sport, and treating any meniscus damage found at the same time all influence the outcome more than which tendon was used.
Schedule an ACL Consultation in New York City
Graft choice is worth understanding before surgery rather than after, and it is a conversation rather than a formula, since age, sport, occupation, and whether you kneel regularly all point in different directions. Dr. Struhl evaluates ACL injuries at his Manhattan and White Plains offices. Contact the practice to schedule an appointment.
