Authors
John ConnorsAntonio CusanoJayson SaleetKevin Anthony HaoKristian EfremovRobert L. ParisienRomain SeilXinning Li
Topics
Knee injuries and reconstruction techniquesTendon Structure and TreatmentFoot and Ankle SurgeryA Systematic Review and Meta-analysis ||Background: Anterior cruciate ligament (ACL) tears are frequent injuries in athletes that often require surgical reconstruction so that patients may return to their previous levels of performance. While existing data on patient-reported outcomes are similar between bone–patellar tendon–bone (BTB) and hamstring tendon (HT) autografts, the literature regarding return to sport (RTS), return to previous levels of sport activity, and graft failure rate remains limited. Purpose: To compare rates of RTS, return to previous activity levels, and graft retears among athletes undergoing primary ACL reconstruction using a BTB versus HT autograft. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: The MEDLINE, Embase, and Cochrane Library databases were queried, and studies reporting on RTS after primary ACL reconstruction using a BTB or HT autograft were included. Exclusion criteria included revision reconstruction, ACL repair, quadriceps tendon autografts, allografts, graft augmentation, or double-bundle autografts. Rates of RTS, return to previous levels of activity, and retears were extracted and analyzed across included studies. Results: A total of 33 articles met inclusion criteria, with a patient cohort of 4810 athletes. The overall RTS rate for all athletes was 80.4% (95% CI, 75.3%-84.6%) at a mean follow-up of 35.7 months, with 54.6% (95% CI, 48.5%-60.6%) returning to preinjury levels of activity. No significant difference was found between BTB and HT autografts with respect to rates of RTS, return to pre injury activity levels, or reruptures. The overall RTS rate in patients after primary ACL reconstruction with a BTB autograft was 83.3% (95% CI, 77.0%-88.2%), with 56.1% (95% CI, 49.3%-62.7%) returning to preinjury levels of activity. Conversely, the over all RTS rate in patients after primary ACL reconstruction with an HT autograft was 77.9% (95% CI, 70.3%-84.0%), with 53.5% (95% CI, 42.8%-63.9%) returning to preinjury levels of activity. The overall graft rerupture rate for the entire patient cohort was 3.6% (95% CI, 2.5%-5.1%), for patients with BTB grafts was 3.2% (95% CI, 1.9%-5.3%), and for patients with HT grafts was 4.4% (95% CI, 2.8%-6.8%). Conclusion: Primary ACL reconstruction using BTB autografts demonstrated similar rates of RTS, return to previous activity lev els, and reruptures compared with reconstruction using HT autografts. Keywords: knee; ACL; return to sport; graftAn anterior cruciate ligament (ACL) tear is a frequent sport-related knee injury that may require surgical inter vention. More than 175,000 ACL reconstruction proce dures are performed each year in the United States, with a prevalence of 1 in 3500 patients, most often occurring in young athletes.An ACL rupture is a devastating, potentially season- or career-ending injury for athletes,The American Journal of Sports Medicine2025;53(8):1996–2006DOI: 10.1177/036354652412957132025 The Author(s)Clinical Sports Medicine Update with some literature suggesting a return-to-sport (RTS) rate of up to only 51% without restrictions by 6 months.4,26The primary goal for a surgical intervention is to restore knee stability and function so as to allow athletes to not only return to their preinjury levels of play but to do so with a relatively low risk of reinjuries.5,6,58A combination of modifiable and nonmodifiable factors is carefully considered when assessing a patient’s ability to return to sport after ACL construction. Broadly speak ing, Shrier54 synthesized this return into 3 main concepts: tissue health, tissue stress, and risk tolerance modifiers. Other factors include the extent of the injury, surgical technique, progression throughout the rehabilitation pro cess, and one’s psychological readiness and motivation to return. Understanding the effect of psychological factors on RTS is critical, as even athletes with maximal function and clinical outcomes may still fail to return to sport at their preinjury levels.9While there has been an emergence of new surgical techniques to treat an ACL rupture, including ACL repair, different autograft options, and the addition of laterally based augmentation (anterolateral ligament reconstruc tion and lateral extra-articular tenodesis), ACL reconstruc tion with an autologous bone–patellar tendon–bone (BTB) or hamstring tendon (HT) graft remains the standard of care. The advantages and disadvantages of each technique have been well described, with BTB autografts reproduc ibly demonstrating higher rates of anterior knee pain, larger incisions at the time of graft harvest, and possible extensor strength deficits.16,25,45,52Similarly, HT auto grafts may confer prolonged knee flexion weakness, saphe nous nerve damage and sensory loss, and graft creep, possibly resulting in persistent postoperative rotational instability in the setting of an intact graft.25,32,33Despite these potential limitations, large meta-analyses have dem onstrated no differences between these 2 graft options with respect to patient-reported clinical outcomes.14,41However, there continues to be a paucity of quality literature addressing rates of RTS, return to preinjury activity levels, and reruptures between these 2 popular graft types in the athletic population. A recent systematic review found that while the majority of elite athletes returned to their previ ous levels of sport, they did so at a level that was lower than their preinjury state.41A separate systematic review and meta-analysis of 20 studies published before 2018 demonstrated higher overall RTS rates in athletes with BTB autografts but no differences in the rates of return to preinjury activity levels or reruptures.Nonetheless, the current literature on RTS after primary ACL recon struction with BTB and HT autografts is limited to low level studies. This systematic review and meta-analysis sought to provide a current updated comparison of the rates of RTS, return to preinjury activity levels, and rerup tures in athletes who have undergone primary ACL recon struction with a BTB versus HT autograft.
About
PublishedJan 21, 2025
TypeReview
Citations29
References62