There is no question in my mind that the ideal ACL graft for an active older patient who is uncomfortable with an allograft is a quadrupled semitendinosus autograft. By quadrupling the tendon, sufficient size and strength of the graft can be achieved. The fact that the quadrupled graft may be shorter can easily be accommodated by using an all-inside technique with bony sockets. With the harvesting of only a single hamstring, the risk of harvest morbidity is low and there is little early postoperative pain. This allows early weight-bearing and shorter time on crutches, which should decrease the risk of deep vein thrombosis or falls. The harvesting is relatively straightforward and can be performed quickly without a tourniquet. Any resulting minor hamstring weakness is unlikely to be noticed in these patients. With respect to concerns about graft retear, because the risk of ACL graft retear declines with age, as much as 50% for each decade of life, retear rates should be low. There is a reason hamstring grafts are the most commonly used grafts for ACL reconstruction worldwide and the benefits of this graft choice are amplified in the older population. In addition, any potential downsides of hamstring graft use are minimized in this age group.

Christopher C. Kaeding, MD, is executive director of sports medicine at The Ohio State University Wexner Medical Center in Columbus, Ohio.