A meta-analysis of bone-patellar tendon-bone autograft versus four-strand hamstring tendon autograft for anterior cruciate ligament reconstruction

Knee. 2015 Mar;22(2):100-10. doi: 10.1016/j.knee.2014.11.014. Epub 2014 Dec 11.


Background: There is a lack of comprehensive studies comparing the clinical outcome of anterior cruciate ligament (ACL) reconstruction with either a bone-patellar tendon-bone (BPTB) or four-strand hamstring tendon (4SHT) autografts. The optimal choice of graft for anterior cruciate ligament reconstruction remains controversial.

Purpose: The objective of this study was to evaluate the effectiveness of BPTB autografts versus 4SHT autografts for the reconstruction of ACL.

Methods: A systematical search of literature was performed in Pubmed, Embase, and the Cochrane library to identify published clinical prospective studies relevant to ACL reconstruction comparing BPTB and 4SHT autografts. The results of the eligible studies were analysed in terms of instrumented laxity measurements, Lachman test, pivot shift test, objective International Knee Documentation Committee (IKDC) scores, return to preinjury activity level, and morbidity of graft failure, anterior knee pain, kneeling pain, extension deficit, and flexion deficit. Study quality was assessed by using the Jadad scale for randomized clinical trial (RCT) and the Newcastle-Ottawa Scale (NOS) for prospective cohort study (PCS). Two reviewers independently assessed each study for quality and extracted data. Subgroup analysis of the primary outcomes was conducted according to the type of study design (RCT or PCS).

Results: Twenty-two studies, with 931 patients in the BPTB group and 999 patients in the 4SHT group, met the inclusion criteria. Fourteen studies were randomized controlled trials, and eight were prospective cohort studies. The results of the meta-analysis showed that there were no significant differences between BPTB and 4SHT in terms of instrumented laxity measurements (P=0.06), Lachman test (P=0.58), objective IKDC scores (P=0.31), graft failure (P=0.45), extension deficit (P=0.06) and flexion deficit (P=0.63). However, outcomes in favour of BPTB were found in terms of pivot shift test (P=0.01) and return to preinjury activity level (P=0.03); outcome measures that favours 4SHT included anterior knee pain (P<0.01) and kneeling pain (P<0.01). These findings were still robust during the sensitivity analysis. Results from subgroup analysis of the primary outcomes were consistent with the overall analysis.

Conclusion: Based on the results above, ACL reconstruction with BPTB autografts might be superior in resuming rotation stability of the knee joint and allow patients to return to higher levels of activity in comparison with 4SHT autografts. Whereas, postoperative complications of the knee joint were lower for 4SHT autografts than for BPTB autografts. There was insufficient evidence to identify which of the two types of grafts was significantly better for ACL reconstruction considering the limitations of this study. More high-quality randomized controlled trials with strictly specified inclusion criteria are highly required before drawing a reliable conclusion.

Keywords: ACL reconstruction; Autograft; Patellar tendon; four-strand hamstring tendon; meta-analysis.

Publication types

  • Meta-Analysis
  • Review

MeSH terms

  • Anterior Cruciate Ligament / surgery*
  • Anterior Cruciate Ligament Injuries
  • Anterior Cruciate Ligament Reconstruction / methods*
  • Bone-Patellar Tendon-Bone Grafting / methods*
  • Humans
  • Patellar Ligament / surgery*
  • Range of Motion, Articular
  • Tendons / transplantation*
  • Transplantation, Autologous