AUTOGRAFT SOURCE
When performing an ACL reconstruction with autograft for skeletally mature patients, surgeons may favor BTB to reduce the risk of graft failure or infection, or hamstring to reduce the risk of anterior or kneeling pain.

Rationale

The autograft source recommendation was downgraded one level due to variable size of hamstring autografts. A total of eleven high quality and two moderate quality studies were identified to evaluate the comparison of bone patellar bone autograft and hamstring autograft. In the largest randomized control trial, Mohtandi (2019) reported on longer term data (5 years) in a randomized control trail between double bundle ACL, hamstring autograft, and bone patellar bone autograft with a total of 353 patients at 5-year follow up. This study demonstrates lower graft ruptures/revision in the bone patella bone autograft compared to the others.  Added benefits of bone patella bone autograft compared to hamstring autograft were also noted in other high quality studies by Laboute (2018) and Drogset (2010). Bone patellar bone was also favored based on other studies (Maletis 2016, Sevimil 2020, Rousseau 2019, Lord 2020, King 2020, Rahardja 2020), however several have noted bone patellar bone associated with more knee pain (Rousseau 2019, Webster 2016, Mohtadi 2016).

Benefits/Harms of Implementation

Surgeon and patient preference will be part of informed decision making to guide graft choice of ACL reconstruction.

Outcome Importance

Graft re-tear is a very important outcome, perhaps the most important outcome, particularly in younger patients returning to high level activity and sport.  Infection is rare but challenging complication. The importance of kneeling pain is likely patient specific.

Cost Effectiveness/Resource Utilization

Likely cost neutral overall with shift in fixation methods but minimal otherwise. 

Acceptability

Use of bone patellar bone and hamstring autograft are readily acceptable as these grafts should be part of the armamentarium of all surgeons performing ACL reconstruction.

Feasibility

Implementation is feasible as bone patellar bone and hamstring autograft should be part of the armamentarium of all surgeons performing ACL reconstruction.

Future Research

Future research should evaluate the long-term consequences of differing graft options, as well as relative cost effectiveness.  Quad tendon autograft deserves further study as an emerging option for ACL reconstruction.