Current evidence around patellar tendon graft in ACLR for high-risk patients: current concepts Article Swipe

Hamstrings and patellar tendon (PT) are the most common autografts used to perform anterior cruciate ligament (ACL) reconstructions. The debate to know which graft should be better has been going on for decades. However, in relation to underpowered studies, no strong conclusions have been drawn until recently. Indeed, there was a need for a greater magnitude of data and assessment of specific population to properly compare these grafts. Our objective was to provide a current review based on recent scientific publications with high level of evidence. Registries have provided conclusive information. The Scandinavian registry showed lower failure rate for bone–patellar tendon–bone (BPTB) versus hamstring tendon (HT) at 5-year follow-up in over 45 000 patients (2.8% vs 4.2%; p<0.001). In the Norwegian registry, with 12 643 patients included, higher revision rates were recorded in HT graft versus BPTB graft at all follow-up times (2.8% vs 0.7% at 2 years and 5.1% vs 2.1% at 5 years). Moreover, as far as high-risk profile patients were concerned, this difference was even more significant. This trend has also been confirmed more recently in a study when assessing young females, showing that the failure rate amounted to 6.4% in the PT group while it reached 17.5% in the HT group at 3.7-year follow-up (p=0.02). ACL graft selection should be a discussion between the physician and the patient, taking into consideration age, activity level and occupation. Within the high-risk patient group however, scientific evidence supports the PT as the gold standard for ACL reconstruction. Hamstrings and patellar tendon (PT) are the most common autografts used to perform anterior cruciate ligament (ACL) reconstructions. The debate to know which graft should be better has been going on for decades. However, in relation to underpowered studies, no strong conclusions have been drawn until recently. Indeed, there was a need for a greater magnitude of data and assessment of specific population to properly compare these grafts. Our objective was to provide a current review based on recent scientific publications with high level of evidence. Registries have provided conclusive information. The Scandinavian registry showed lower failure rate for bone–patellar tendon–bone (BPTB) versus hamstring tendon (HT) at 5-year follow-up in over 45 000 patients (2.8% vs 4.2%; p<0.001). In the Norwegian registry, with 12 643 patients included, higher revision rates were recorded in HT graft versus BPTB graft at all follow-up times (2.8% vs 0.7% at 2 years and 5.1% vs 2.1% at 5 years). Moreover, as far as high-risk profile patients were concerned, this difference was even more significant. This trend has also been confirmed more recently in a study when assessing young females, showing that the failure rate amounted to 6.4% in the PT group while it reached 17.5% in the HT group at 3.7-year follow-up (p=0.02). ACL graft selection should be a discussion between the physician and the patient, taking into consideration age, activity level and occupation. Within the high-risk patient group however, scientific evidence supports the PT as the gold standard for ACL reconstruction. Current concepts•There is increasing scientific evidence that patellar tendon has lower failure rate than hamstring autograft in anterior cruciate ligament reconstruction.•This difference is greater in high-risk profile patients (young patients and females). •There is increasing scientific evidence that patellar tendon has lower failure rate than hamstring autograft in anterior cruciate ligament reconstruction.•This difference is greater in high-risk profile patients (young patients and females). Future perspectives•There is a need to assess if bone–patellar tendon–bone is superior to hamstring in other postoperative areas (return to sport, pain, functional outcomes, laxity, long-term osteoarthritis).•New techniques (multistrand hamstrings, addition of an anterolateral procedure) or other autografts (quadriceps tendon, peroneal tendon) need to be assessed in a large scale to properly compare their results with the patellar tendon or hamstrings. •There is a need to assess if bone–patellar tendon–bone is superior to hamstring in other postoperative areas (return to sport, pain, functional outcomes, laxity, long-term osteoarthritis).•New techniques (multistrand hamstrings, addition of an anterolateral procedure) or other autografts (quadriceps tendon, peroneal tendon) need to be assessed in a large scale to properly compare their results with the patellar tendon or hamstrings.