Purpose: No graft tissue has consistently shown superiority over others for reconstruction
of the anterior cruciate ligament (ACL). Bone–patellar tendon-bone (BPTB) and doubled
hamstring tendon (semitendinosus and gracilis) (HT) are the most commonly used autologous
grafts. We performed a meta-analysis to compare the effectiveness of ACL reconstruction
using either BPTB or HT grafts. Type of Study: Systematic review and meta-analysis. Methods: We searched the MEDLINE database (1966 to April 2003) for English-language randomized
or prospective studies comparing BPTB and 3- or 4-strand HT grafts used for ACL reconstruction.
For inclusion, studies were required to follow identical rehabilitation protocols
within each study, and provide subjective or objective outcome data after a minimum
average 2-year follow-up. Comparison data between BPTB and HT for each identified
outcome measure were combined using a random-effects model meta-analysis. Results: Eleven reports fulfilled the criteria for inclusion. Outcomes favoring BPTB were
found in the following outcome measures: normal Lachman examination (relative risk
[RR], 0.91; 95% confidence interval [CI], 0.83–0.99; P = .025), normal pivot-shift (RR, 0.94; 95% CI, 0.88–1.0; P = .067), KT-1000 manual-maximum side-to-side difference of ≤3 mm (RR, 0.75; 95% CI,
0.55–1.01; P = .057), and fewer reconstructions resulting in flexion loss >5° (RR, 1.41; 95% CI,
1.01–1.96; P = .04). Intermediate level laxity was more common with the HT graft, as shown by
higher rates of abnormal Lachman >0 (RR, 1.22; 95% CI, 0.99–1.5; P = .06), pivot-shift >0 (RR, 1.3; 95% CI, 0.96–1.75; P = .09), and KT-1000 manual-maximum side-to-side differences >3 mm (RR, 1.64; 95%
CI, 1.13–2.39; P = .01). Outcome measures that favored HT were absence of patellofemoral crepitance
(RR, 1.08; 95% CI, 1.01–1.15; P = .03), fewer results with extension loss >5° (RR, 0.56; 95% CI, 0.3–1.03; P = .06), and kneeling pain. The incidence of instability, as defined by Lachman grade
2, pivot-shift grade 2, or KT-1000 manual-maximum side-to-side difference >5 mm, was
not significantly different between the 2 grafts. All other outcome measures were
not significantly different. Conclusions: The data presented in this meta-analysis show that the incidence of instability is
not significantly different between the BPTB and HT grafts. However, BPTB was more
likely to result in reconstructions with normal Lachman, normal pivot-shift, KT-1000
manual-maximum side-to-side difference <3 mm, and fewer results with significant flexion
loss. In contrast, HT grafts had a reduced incidence of patellofemoral crepitance,
kneeling pain, and extension loss. The choice of graft by the patient and surgeon
must be individualized, and the results of this meta-analysis can aid in the decision
by clarifying the risks and benefits of each surgical approach. Level of Evidence: Level I.
Key Words
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© 2005 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
