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.
- Webster, K. E., Feller, J. A., Hartnett, N., Leigh, W. B., Richmond, A. K. Comparison of Patellar Tendon and Hamstring Tendon Anterior Cruciate Ligament Reconstruction: A 15-Year Follow-up of a Randomized Controlled Trial. American Journal of Sports Medicine 2016; 1: 83-90
- Sevimli, R., Gormeli, G., Polat, H., Kilinc, O., Turkmen, E., Aslanturk, O. Comparison of medium-term revision rates after autograft and allograft anterior cruciate ligament reconstruction. Annali Italiani di Chirurgia 2020; 0: 11
- Rousseau, R., Labruyere, C., Kajetanek, C., Deschamps, O., Makridis, K. G., Djian, P. Complications After Anterior Cruciate Ligament Reconstruction and Their Relation to the Type of Graft: A Prospective Study of 958 Cases. American Journal of Sports Medicine 2019; 11: 2543-2549
- Rahardja, R., Zhu, M., Love, H., Clatworthy, M. G., Monk, A. P., Young, S. W. Effect of Graft Choice on Revision and Contralateral Anterior Cruciate Ligament Reconstruction: Results From the New Zealand ACL Registry. American Journal of Sports Medicine 2020; 1: 63-69
- Mohtadi, N., Chan, D., Barber, R., Paolucci, E. O. Reruptures, Reinjuries, and Revisions at a Minimum 2-Year Follow-up: A Randomized Clinical Trial Comparing 3 Graft Types for ACL Reconstruction. Clinical Journal of Sport Medicine 2016; 2: 96-107
- Mohtadi, N. G., Chan, D. S. A Randomized Clinical Trial Comparing Patellar Tendon, Hamstring Tendon, and Double-Bundle ACL Reconstructions: Patient-Reported and Clinical Outcomes at 5-Year Follow-up. Journal of Bone & Joint Surgery - American Volume 2019; 11: 949-960
- Maletis, G. B., Chen, J., Inacio, M. C., Funahashi, T. T. Age-Related Risk Factors for Revision Anterior Cruciate Ligament Reconstruction: A Cohort Study of 21,304 Patients From the Kaiser Permanente Anterior Cruciate Ligament Registry. American Journal of Sports Medicine 2016; 2: 331-6
- Lord, L., Cristiani, R., Edman, G., Forssblad, M., Stalman, A. One sixth of primary anterior cruciate ligament reconstructions may undergo reoperation due to complications or new injuries within 2 years. Knee Surgery, Sports Traumatology, Arthroscopy 2020; 0: 29
- Laboute, E., James-Belin, E., Puig, P. L., Trouve, P., Verhaeghe, E. Graft failure is more frequent after hamstring than patellar tendon autograft. Knee Surgery, Sports Traumatology, Arthroscopy 2018; 12: 3537-3546
- King, E., Richter, C., Jackson, M., Franklyn-Miller, A., Falvey, E., Myer, G. D., Strike, S., Withers, D., Moran, R. Factors Influencing Return to Play and Second Anterior Cruciate Ligament Injury Rates in Level 1 Athletes After Primary Anterior Cruciate Ligament Reconstruction: 2-Year Follow-up on 1432 Reconstructions at a Single Center. American Journal of Sports Medicine 2020; 4: 812-824
- Drogset, J. O., Strand, T., Uppheim, G., Odegård, B., Bøe, A., Grøntvedt, T. Autologous patellar tendon and quadrupled hamstring grafts in anterior cruciate ligament reconstruction: a prospective randomized multicenter review of different fixation methods. Knee Surgery, Sports Traumatology, Arthroscopy 2010; 8: 1085-93