Strong evidence supports that in patients undergoing intra-articular ACL reconstruction using autograft tissue the practitioner should use bone-patellar tendon-bone or hamstring-tendon grafts, because the measured outcomes are similar.

There were four high-strength, and 19 moderate-strength studies included in this recommendation. 3, 7,10, 10, 13, 22, 27, , 28, 34, 49, 52, 63, 64, 86, 95, 96, 100, 115, 118, 119, 122 Graft choice did not matter with respect to stability testing in three high-strength studies  and ten moderate-strength studies.10, 16, 26, 48, 72, 111, 159, 165, 243, 287,294, 308   Patient satisfaction, normal IKDC score  , and graft failure were also not different between the two graft choices.10, 10, 13, 22, 27, 28, 34, 49, 52, 63, 64, 96, 115

However, significantly more post-operative kneeling pain was present in the patella tendon group as demonstrated by two high-strength studies and one moderate-strength study.28, 52, 96
Potential Harms of Implementation
Possible graft failure in either graft is possible and reported
Future Research
Recommend evaluation of radiographic and symptomatic osteoarthritis as mid to long term outcome measures in comparison studies between extensor mechanism grafts (patellar and quad tendons) and hamstring grafts. Additional research comparing ipsilateral grafts to contralateral grafts is also needed.

  1. (10) Anderson AF, Snyder RB, Lipscomb AB, Jr. Anterior cruciate ligament reconstruction. A prospective randomized study of three surgical methods. Am J Sports Med 2001;29:272-279.
  2. (100) Shaieb MD, Kan DM, Chang SK, Marumoto JM, Richardson AB. A prospective randomized comparison of patellar tendon versus semitendinosus and gracilis tendon autografts for anterior cruciate ligament reconstruction. Am J Sports Med 2002;30:214-220.
  3. (115) Tow BP, Chang PC, Mitra AK, Tay BK, Wong MC. Comparing 2-year outcomes of anterior cruciate ligament reconstruction using either patella-tendon or semitendinosus-tendon autografts: a non-randomised prospective study. J Orthop Surg (Hong Kong) 2005;13:139-146.
  4. (118) Volpi P, Marinoni L, Bait C, Galli M, de GL. Tibial fixation in anterior cruciate ligament reconstruction with bone-patellar tendon-bone and semitendinosus-gracilis autografts: a comparison between bioabsorbable screws and bioabsorbable cross-pin fixation. Am J Sports Med 2009;37:808-812.
  5. (119) Webster KE, Feller JA, Hameister KA. Bone tunnel enlargement following anterior cruciate ligament reconstruction: a randomised comparison of hamstring and patellar tendon grafts with 2-year follow-up. Knee Surg Sports Traumatol Arthrosc 2001;9:86-91.
  6. (122) Zaffagnini S, Marcacci M, Lo PM, Giordano G, Iacono F, Neri MP. Prospective and randomized evaluation of ACL reconstruction with three techniques: a clinical and radiographic evaluation at 5 years follow-up. Knee Surg Sports Traumatol Arthrosc 2006;14:1060-1069.
  7. (13) Beynnon BD, Johnson RJ, Fleming BC et al. Anterior cruciate ligament replacement: comparison of bone-patellar tendon-bone grafts with two-strand hamstring grafts. A prospective, randomized study. J Bone Joint Surg Am 2002;84-A:1503-1513.
  8. (22) Comba D, Sandrucci G, Graziano E, Regis G, Cenna E. Arthroscopic reconstruction of the ACL with double-looped semitendinosus and gracilis tendons and fixation with bioabsorbable interference screws. Medium-term results. Journal of Sports Traumatology and Related Research 1999;21:145-154.
  9. (27) Ejerhed L, Kartus J, Sernert N, Kohler K, Karlsson J. Patellar tendon or semitendinosus tendon autografts for anterior cruciate ligament reconstruction? A prospective randomized study with a two-year follow-up. Am J Sports Med 2003;31:19-25.
  10. (28) Feller JA, Webster KE. A randomized comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction. Am J Sports Med 2003;31:564-573.
  11. (3) Aglietti P, Giron F, Buzzi R, Biddau F, Sasso F. Anterior cruciate ligament reconstruction: bone-patellar tendon-bone compared with double semitendinosus and gracilis tendon grafts. A prospective, randomized clinical trial. J Bone Joint Surg Am 2004;86-A:2143-2155.
  12. (34) Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ 2013;346:f232.
  13. (49) Holm I, Oiestad BE, Risberg MA, Aune AK. No difference in knee function or prevalence of osteoarthritis after reconstruction of the anterior cruciate ligament with 4-strand hamstring autograft versus patellar tendon-bone autograft: a randomized study with 10-year follow-up. Am J Sports Med 2010;38:448-454.
  14. (52) Ibrahim SA, Al-Kussary IM, Al-Misfer AR, Al-Mutairi HQ, Ghafar SA, El Noor TA. Clinical evaluation of arthroscopically assisted anterior cruciate ligament reconstruction: patellar tendon versus gracilis and semitendinosus autograft. Arthroscopy 2005;21:412-417.
  15. (63) Leal-Blanquet J, Alentorn-Geli E, Tuneu J, Valenti JR, Maestro A. Anterior cruciate ligament reconstruction: a multicenter prospective cohort study evaluating 3 different grafts using same bone drilling method. Clin J Sport Med 2011;21:294-300.
  16. (64) Liden M, Ejerhed L, Sernert N, Laxdal G, Kartus J. Patellar tendon or semitendinosus tendon autografts for anterior cruciate ligament reconstruction: a prospective, randomized study with a 7-Year follow-up. Am J Sports Med 2007;35:740-748.
  17. (7) Ahlden M, Kartus J, Ejerhed L, Karlsson J, Sernert N. Knee laxity measurements after anterior cruciate ligament reconstruction, using either bone-patellar-tendon-bone or hamstring tendon autografts, with special emphasis on comparison over time. Knee Surg Sports Traumatol Arthrosc 2009;17:1117-1124.
  18. (86) Pinczewski LA, Lyman JR, Salmon LJ et al. A ten year prospective comparison of patellar & hamstring tendon grafts for ACL reconstruction [abstract]. American Academy of Orthopaedic Surgeons Annual Meeting ; 2007 Feb 14 18 ; San Diego www3 aaos org /education/anmeet /anmt2007 /education cfm 2007.
  19. (95) Roe J, Pinczewski LA, Russell VJ, Salmon LJ, Kawamata T, Chew M. A 7-year follow-up of patellar tendon and hamstring tendon grafts for arthroscopic anterior cruciate ligament reconstruction: differences and similarities. Am J Sports Med 2005;33:1337-1345.
  20. (96) Sajovic M, Strahovnik A, Dernovsek MZ, Skaza K. Quality of life and clinical outcome comparison of semitendinosus and gracilis tendon versus patellar tendon autografts for anterior cruciate ligament reconstruction: an 11-year follow-up of a randomized controlled trial. Am J Sports Med 2011;39:2161-2169.