BTB Versus Hamstring Autograft After Primary ACL Reconstruction

Key Takeaways

• No significant between-graft difference was observed in return to sport, return to preinjury activity, or rerupture.
• Across all athletes, 80.4% returned to sport (95% CI, 75.3%-84.6%) and 54.6% returned to preinjury activity (95% CI, 48.5%-60.6%).
• The review pooled 33 articles and 4,810 athletes, with mean follow-up of 35.7 months.

An overall return-to-sport rate of 80.4% anchored a systematic review and meta-analysis of BTB versus hamstring autografts after primary ACL reconstruction in athletes. Across included athlete cohorts, bone-patellar tendon-bone and hamstring tendon autografts showed no significant difference in return to sport, return to preinjury activity, or rerupture after surgery. The review focused on postoperative return and failure outcomes, which were less extensively reported than patient-reported results in prior literature. Overall, the pooled evidence indicated similar postoperative results for these two commonly used autograft strategies in athletes.

The review focused specifically on athletes undergoing primary ACL reconstruction with either BTB or hamstring tendon autograft. It pooled 33 articles covering 4,810 athletes, with mean follow-up of 35.7 months, and was described as Level 4 evidence. Investigators searched MEDLINE, Embase, and the Cochrane Library and extracted rates from eligible studies reporting return to sport after primary reconstruction with either graft. Exclusions included revision reconstruction, ACL repair, quadriceps tendon autografts, allografts, graft augmentation, and double-bundle autografts. Endpoints were return to sport, return to previous activity level, and graft rerupture across the included athlete studies.

By graft type, the pooled return-to-sport rate was 83.3% for BTB autograft (95% CI, 77.0%-88.2%) and 77.9% for hamstring autograft (95% CI, 70.3%-84.0%) in the pooled analysis. Return to preinjury activity was 56.1% with BTB (95% CI, 49.3%-62.7%) and 53.5% with hamstring autograft (95% CI, 42.8%-63.9%), respectively. Return-to-sport estimates were higher than return to previous activity for both grafts, and researchers did not identify a statistically significant between-graft difference for either return outcome in the pooled comparison.

The overall graft rerupture rates were 3.6% for the full cohort (95% CI, 2.5%-5.1%). BTB autograft had a pooled rerupture rate of 3.2% (95% CI, 1.9%-5.3%), while hamstring autograft was 4.4% (95% CI, 2.8%-6.8%). Investigators described no significant between-graft difference for rerupture in the pooled data from these included studies. They concluded that BTB reconstruction showed similar rates of return to sport, return to previous activity, and rerupture compared with hamstring autografts.