Outcomes Following ACL Reconstruction Based on Graft Type: Are all Grafts Equivalent?
Purpose of Review
Anterior cruciate ligament reconstruction is one of the most common orthopedic procedures performed, accounting for over 200,000 cases annually. Despite the high prevalence, there is still much debate as to the optimal graft choice. The purpose of this review is to evaluate the current literature and discuss the reported outcomes for the most common graft choices.
The most common autografts being used include bone-patellar tendon-bone (BPTB), hamstring tendon (HT), and quadriceps tendon (QT). Hamstring tendon might have a slightly higher re-tear rate when compared with BPTB (2.84 versus 2.80). However, BPTB has a higher rate of anterior knee and kneeling pain in the short- and mid-term follow-up. This has not been shown to be the case in long-term follow-up. Allograft is a viable option for revisions and primaries in patients greater than 35 years old; however, re-tear rate increases significantly in younger patients.
ACL reconstruction graft choice is a highly studied and yet still exceedingly debated topic. Most large studies report either no significant difference or a small difference in failure rate and outcome scores between the different autograft choices. Allografts have been demonstrated to have an increased risk of failure in younger athletes and should be reserved for revision cases and those aged 35 years and older. Graft choice should ultimately be decided upon based on surgeon comfort and experience and individual patient characteristics.
KeywordsACL reconstruction Bone-patellar tendon-bone autograft Hamstring autograft Quadriceps autograft ACL graft choice
Compliance with Ethical Standards
Conflict of Interest
Matthew Widner, Mark Dunleavy, and Scott Lynch declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 8.• Tibor L, Chan PH, Funahashi TT, Wyatt R, Maletis GB, Inacio MC. Surgical technique trends in primary ACL reconstruction from 2007 to 2014. J Bone Joint Surg Am. 2016;98(13):1079–89. https://doi.org/10.2106/JBJS.15.00881Surgical techniques regarding ACL reconstruction are constantly in flux. This large retrospective review of over 21,686 community cases revealed that although femoral drilling technique has largely changed over the 7-year study period, the incidence rates of specific graft choice remained steady. CrossRefPubMedGoogle Scholar
- 10.Buck BE, Malinin T, Brown MD. Bone transplantation and human immunodeficiency virus. An estimate of risk of acquired immunodeficiency syndrome (AIDS). Clin Orthop Relat Res. 1989;(240):129–36.Google Scholar
- 19.Caborn DN, Urban WP Jr, Johnson DL, Nyland J, Pienkowski D. Biomechanical comparison between BioScrew and titanium alloy interference screws for bone-patellar tendon-bone graft fixation in anterior cruciate ligament reconstruction. Arthroscopy. 1997;13(2):229–32.PubMedCrossRefPubMedCentralGoogle Scholar
- 21.Nawabi DH, van der List JP, Williams A. Technical considerations for patellar tendon harvest. In: Nakamura N, Zaffagnini S, Marx R, Musahl V, editors. Controversies in the technical aspects of ACL reconstruction. Berlin: Springer; 2017.Google Scholar
- 22.• Webster KE, Feller JA, Hartnett N, Leigh WB, Richmond AK. Comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction: a 15-year follow-up of a randomized controlled trial. Am J Sports Med. 2016;44(1):83–90 This long-term follow-up provided level one data examining the results of patellar tendon vs. hamstring tendon grafts at 15 years. Although some graft differences were observed in the author’s earlier reviews, it appears that they disappeared at 15 years, making the two graft choices quite comparable. PubMedCrossRefPubMedCentralGoogle Scholar
- 28.• Hardy A, Casabianca L, Andrieu K, Baverel L, Noailles T, Junior French Arthroscopy Society. Complications following harvesting of patellar tendon or hamstring tendon grafts for anterior cruciate ligament reconstruction: Systematic review of literature. Orthop Traumatol Surg Res. 2017;103(8):S245–8 A large systematic review was performed including data from 36 articles and found that the main complication of hamstring harvesting was damage to the infrapatellar branches of the saphenous nerve, while patellar tendon harvesting led to significant numbers of anterior knee pain. PubMedCrossRefGoogle Scholar
- 30.Konrath JM, Vertullo CJ, Kennedy BA, Bush HS, Barrett RS, Lloyd DG. Morphologic characteristics and strength of the hamstring muscles remain altered at 2 years after use of a hamstring tendon graft in anterior cruciate ligament reconstruction. Am J Sports Med. 2016;44(10):2589–98.PubMedCrossRefGoogle Scholar
- 34.• Hurley ET, Calvo-Gurry M, Withers D, Farrington SK, Moran R, Moran CJ. Quadriceps tendon autograft in anterior cruciate ligament reconstruction: a systematic review. Arthroscopy. 2018;34(5):1690–8 Quadriceps tendon continues to emerge as a viable graft option in ACL reconstruction. This recent study included data from 15 clinical trials with over 1,900 patients, and demonstrated comparable knee stability, functional outcomes, and complications with patellar tendon and hamstring tendon grafts. PubMedCrossRefGoogle Scholar
- 37.Mardani-Kivi M, Karimi-Mobarakeh M, Keyhani S, Saheb-Ekhtiari K, Hashemi-Motlagh K, Sarvi A. Hamstring tendon autograft versus fresh-frozen tibialis posterior allograft in primary arthroscopic anterior cruciate ligament reconstruction: a retrospective cohort study with three to six years follow-up. Int Orthop. 2016;40(9):1905–11.PubMedCrossRefGoogle Scholar
- 40.• Condello V, Zdanowicz U, Di Matteo B, Spalding T, Gelber PE, Adravanti P, et al. Allograft tendons are a safe and effective option for revision ACL reconstruction: a clinical review. Knee Surg Sports Traumatol Arthrosc. 2019;27(6):1771–81 Although allograft tendons have a reputation for being a weaker graft choice, they are often considered viable options in the revision setting, especially in older patients. This updated clinical review provides perspective on how to best optimize results using allograft by avoiding excessive irradiation and only selecting them in appropriate settings. PubMedCrossRefPubMedCentralGoogle Scholar
- 42.• Samuelson BT, Webster KE, Johnson NR, Hewett TE, Krych AJ. Hamstring autograft versus patellar tendon autograft for ACL reconstruction: is there a difference in graft failure rate? A meta-analysis of 47,613 patients. Clin Orthop Relat Res. 2017;475(10):2459–68 In this large meta-analysis of primary ACL reconstructions, differences in the results after short- to mid-term follow-up were examined and revealed low failure rates in both groups and minimal differences with regards to laxity, although hamstring autografts did fail at a higher rate than patellar tendon. CrossRefGoogle Scholar
- 43.• Mouarbes D, Menetrey J, Marot V, Courtot L, Berard E, Cavaignac E. Anterior cruciate ligament reconstruction: a systematic review and meta-analysis of outcomes for quadriceps tendon autograft versus bone-patellar tendon-bone and hamstring-tendon autografts. Am J Sports Med. 2019. https://doi.org/10.1177/0363546518825340Updated systematic review comparing the three main choices in autograft selection. After examining 27 studies with over 2800 patients, quadriceps tendon showed comparable clinical and functional outcomes with significantly less harvest site pain compared with patellar tendon, and better functional scores compared with hamstring tendons.
- 44.Kaeding CC, Pedroza AD, Reinke EK, Huston LJ, MOON Consortium, Spindler KP. Risk factors and predictors of subsequent ACL injury in either knee after ACL reconstruction: prospective analysis of 2488 primary ACL reconstructions from the MOON cohort. Am J Sports Med. 2015;43(7):1583–90.PubMedPubMedCentralCrossRefGoogle Scholar
- 45.Hamrin Senorski E, Svantesson E, Baldari A, Ayeni OR, Engebretsen L, Franceschi F, et al. Factors that affect patient reported outcome after anterior cruciate ligament reconstruction-a systematic review of the Scandinavian knee ligament registers. Br J Sports Med. 2019;53(7):410–7.PubMedCrossRefPubMedCentralGoogle Scholar