Outcomes Following Anterior Cruciate Ligament Reconstruction with Patellar Tendon vs Hamstring Autografts: A Systematic Review of Randomized Controlled Trials with a Mean Follow-up of 15 Years

Document Type : SYSTEMATIC REVIEW

Authors

1 Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA

2 Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, MI, USA

Abstract

Background: The two most common surgical treatment modalities for anterior cruciate ligament reconstruction 
(ACL), patellar tendon (PT) and hamstring tendon (HS) autografts, have been shown to have outcomes that are both 
similar and favorable; however, many of these are short or intermediate-term. The objective of this systematic review 
is to evaluate randomized controlled trials (RCTs) with a minimum 10-year follow-up data to compare the long-term 
outcomes of ACL reconstructions performed using PT and HS autografts.
Methods: This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and MetaAnalyses) guidelines. A search of three databases (PubMed, Cochrane and EMBASE) was performed to identify RCTs 
with a minimum of 10-year follow-up that compared clinical and/or functional outcomes between PT and HS autografts. 
Results: Four RCTs with a total of 299 patients were included in the study. The mean follow-up ranged from 10.2 to 17 
years (mean, 14.79 years). No significant differences in knee laxity or clinical outcome scores were demonstrated in 
any of the studies. One study found that PT autografts were significantly more likely to have osteoarthritis identified by 
radiographic findings. Two studies found that patients with PT autografts reported increase kneeling pain, while none of 
the four studies reported a difference in anterior knee pain. There were no significant differences in graft failure rates.
Conclusion: This review demonstrates no long-term difference in clinical or functional outcomes between PT and HS 
autografts. However, radiographic and subjective outcomes indicate that patients with PT autografts may experience 
greater kneeling pain and osteoarthritis. Therefore, orthopaedic surgeons should consider patient-centric factors when 
discussing graft options with patients.
Level of evidence: II

Keywords

References

1. Mall NA, Chalmers PN, Moric M, Tanaka MJ, Cole BJ, 
Bach Jr BR, et al. Incidence and trends of anterior 
cruciate ligament reconstruction in the United 
States. The American journal of sports medicine. 
2014;42(10):2363-70.
2. Gifstad T, Sole A, Strand T, Uppheim G, Grontvedt T, 
Drogset JO. Long-term follow-up of patellar tendon 
grafts or hamstring tendon grafts in endoscopic 
ACL reconstructions. Knee Surg Sports Traumatol 
Arthrosc. 2013;21(3):576-83.
3. Maletis GB, Cameron SL, Tengan JJ, Burchette RJ. A 
prospective randomized study of anterior cruciate 
ligament reconstruction: a comparison of patellar 
tendon and quadruple-strand semitendinosus/
gracilis tendons fixed with bioabsorbable interference 
screws. Am J Sports Med. 2007;35(3):384-94.
4. Mohtadi N, Chan D, Barber R, Oddone Paolucci E. 
A Randomized Clinical Trial Comparing Patellar 
Tendon, Hamstring Tendon, and Double-Bundle 
ACL Reconstructions: Patient-Reported and Clinical 
Outcomes at a Minimal 2-Year Follow-up. Clin J Sport 
Med. 2015;25(4):321-31.
5. Rahr-Wagner L, Thillemann TM, Pedersen AB, Lind M. 
Comparison of hamstring tendon and patellar tendon  grafts in anterior cruciate ligament reconstruction 
in a nationwide population-based cohort study: 
results from the danish registry of knee ligament 
reconstruction. Am J Sports Med. 2014;42(2):278-84.
6. Dhammi IK, Rehan Ul H, Kumar S. Graft choices for 
anterior cruciate ligament reconstruction. Indian J 
Orthop. 2015;49(2):127-8.
7. Magnussen RA, Carey JL, Spindler KP. Does autograft 
choice determine intermediate-term outcome of 
ACL reconstruction? Knee Surg Sports Traumatol 
Arthrosc. 2011;19(3):462-72.
8. Poehling-Monaghan KL, Salem H, Ross KE, Secrist E, 
Ciccotti MC, Tjoumakaris F, et al. Long-Term Outcomes 
in Anterior Cruciate Ligament Reconstruction: 
A Systematic Review of Patellar Tendon Versus 
Hamstring Autografts. Orthop J Sports Med. 
2017;5(6):2325967117709735.
9. Sajovic M, Vengust V, Komadina R, Tavcar R, Skaza 
K. A prospective, randomized comparison of 
semitendinosus and gracilis tendon versus patellar 
tendon autografts for anterior cruciate ligament 
reconstruction: five-year follow-up. Am J Sports Med. 
2006;34(12):1933-40.
10.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(10):2161-9.
11.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 tendonbone autograft: a randomized study with 10-year 
follow-up. Am J Sports Med. 2010;38(3):448-54.
12.Webster KE, Feller JA, Hartnett N, Leigh WB, Richmond 
AK. Comparison of Patellar Tendon and Hamstring 
Tendon Anterior Cruciate Ligament Reconstruction: A 
15-Year Follow-up of a Randomized Controlled Trial. 
Am J Sports Med. 2016;44(1):83-90.
13.Sajovic M, Stropnik D, Skaza K. Long-term 
Comparison of Semitendinosus and Gracilis Tendon 
Versus Patellar Tendon Autografts for Anterior 
Cruciate Ligament Reconstruction: A 17-Year Followup of a Randomized Controlled Trial. Am J Sports 
Med. 2018;46(8):1800-8.
14.Bjornsson H, Samuelsson K, Sundemo D, Desai N, 
Sernert N, Rostgard-Christensen L, et al. A Randomized 
Controlled Trial With Mean 16-Year Follow-up 
Comparing Hamstring and Patellar Tendon Autografts 
in Anterior Cruciate Ligament Reconstruction. Am J 
Sports Med. 2016;44(9):2304-13.
15.Harris JD, Quatman CE, Manring MM, Siston RA, 
Flanigan DC. How to write a systematic review. Am J 
Sports Med. 2014;42(11):2761-8.
16.Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. 
Preferred reporting items for systematic reviews 
and meta-analyses: the PRISMA statement. Int J Surg. 
2010;8(5):336-41.
17.Coleman BD, Khan KM, Maffulli N, Cook JL, Wark 
JD. Studies of surgical outcome after patellar 
tendinopathy: clinical significance of methodological 
deficiencies and guidelines for future studies. 
Victorian Institute of Sport Tendon Study Group. 
Scand J Med Sci Sports. 2000;10(1):2-11.
18.Fu FH, Bennett CH, Lattermann C, Ma CB. Current 
trends in anterior cruciate ligament reconstruction. 
Part 1: Biology and biomechanics of reconstruction. 
Am J Sports Med. 1999;27(6):821-30.
19.Sanders TL, Kremers HM, Bryan AJ, Fruth KM, Larson 
DR, Pareek A, et al. Is Anterior Cruciate Ligament 
Reconstruction Effective in Preventing Secondary 
Meniscal Tears and Osteoarthritis? Am J Sports Med. 
2016;44(7):1699-707.
20.Beynnon BD, Johnson RJ, Fleming BC, Kannus P, 
Kaplan M, Samani J, et al. Anterior cruciate ligament 
replacement: comparison of bone-patellar tendonbone grafts with two-strand hamstring grafts. A 
prospective, randomized study. J Bone Joint Surg Am. 
2002;84(9):1503-13.
21.Cristiani R, Sarakatsianos V, Engstrom B, Samuelsson 
K, Forssblad M, Stalman A. Increased knee laxity 
with hamstring tendon autograft compared to 
patellar tendon autograft: a cohort study of 5462 
patients with primary anterior cruciate ligament 
reconstruction. Knee Surg Sports Traumatol Arthrosc. 
2019;27(2):381-8.
22.Thompson SM, Salmon LJ, Waller A, Linklater J, Roe JP, 
Pinczewski LA. Twenty-Year Outcome of a Longitudinal 
Prospective Evaluation of Isolated Endoscopic 
Anterior Cruciate Ligament Reconstruction With 
Patellar Tendon or Hamstring Autograft. Am J Sports 
Med. 2016;44(12):3083-94.
23.Barenius B, Nordlander M, Ponzer S, Tidermark J, 
Eriksson K. Quality of life and clinical outcome after 
anterior cruciate ligament reconstruction using 
patellar tendon graft or quadrupled semitendinosus 
graft: an 8-year follow-up of a randomized controlled 
trial. Am J Sports Med. 2010;38(8):1533-41.
24.Briggs KK, Lysholm J, Tegner Y, Rodkey WG, Kocher 
MS, Steadman JR. The reliability, validity, and 
responsiveness of the Lysholm score and Tegner 
activity scale for anterior cruciate ligament injuries 
of the knee: 25 years later. Am J Sports Med. 
2009;37(5):890-7.
25.Higgins LD, Taylor MK, Park D, Ghodadra N, Marchant 
M, Pietrobon R, et al. Reliability and validity of the 
International Knee Documentation Committee 
(IKDC) Subjective Knee Form. Joint Bone Spine. 
2007;74(6):594-9.
26.Kahlenberg CA, Nwachukwu BU, Ferraro RA, Schairer 
WW, Steinhaus ME, Allen AA. How Are We Measuring 
Patient Satisfaction After Anterior Cruciate 
Ligament Reconstruction? Orthop J Sports Med. 
2016;4(12):2325967116673971.
27.Keays SL, Bullock-Saxton JE, Keays AC, Newcombe PA, 
Bullock MI. A 6-year follow-up of the effect of graft 
site on strength, stability, range of motion, function, 
and joint degeneration after anterior cruciate 
ligament reconstruction: patellar tendon versus 
semitendinosus and Gracilis tendon graft. Am J Sports  Med. 2007;35(5):729-39.
28.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(4):412-7.
29.Wipfler B, Donner S, Zechmann CM, Springer J, 
Siebold R, Paessler HH. Anterior cruciate ligament 
reconstruction using patellar tendon versus hamstring 
tendon: a prospective comparative study with 9-year 
follow-up. Arthroscopy. 2011;27(5):653-65.
30.Laboute E, James-Belin E, Puig PL, Trouve P, Verhaeghe 
E. Graft failure is more frequent after hamstring than 
patellar tendon autograft. Knee Surg Sports Traumatol 
Arthrosc. 2018;26(12):3537-46.
31.Persson A, Fjeldsgaard K, Gjertsen JE, Kjellsen AB, 
Engebretsen L, Hole RM, et al. Increased risk of 
revision with hamstring tendon grafts compared with 
patellar tendon grafts after anterior cruciate ligament 
reconstruction: a study of 12,643 patients from the 
Norwegian Cruciate Ligament Registry, 2004-2012. 
Am J Sports Med. 2014;42(2):285-91.
32.Xie X, Liu X, Chen Z, Yu Y, Peng S, Li Q. A metaanalysis of bone-patellar tendon-bone autograft 
versus four-strand hamstring tendon autograft for 
anterior cruciate ligament reconstruction. Knee. 
2015;22(2):100-10
The Archives of Bone and Joint Surgery
Volume 10, Issue 4
April 2022
Pages 311-319

Files

History

  • Receive Date: 10 December 2020
  • Accept Date: 24 July 2021
  • First Publish Date: 30 August 2021

Share

How to cite

Statistics