Patellar Tendon or Four-strand Hamstring? A Systematic Review of Autografts for Anterior Cruciate Ligament Reconstruction

The choice of graft for anterior cruciate ligament reconstruction remains controversial. A systematic review was performed to compare bone-patella tendon-bone and four-strand hamstring grafts. Medline (1966 onwards), EMBASE (1980 onwards) and the Cochrane database were searched retrieving 6312 possible articles, but only 6 studies fulfilled all the inclusion criteria. To be included, the study had to be prospective, randomised or quasi-randomised, comparing 4SHS and central third BPTB autografts, inserted using an arthroscopically assisted technique and have a minimum 2-year follow-up for all patients. These studies recruited 526 patients, and 475 were followed for at least 2 years with 235 patients receiving a bone-patella tendon-bone graft and 240 receiving a four-strand hamstring graft. Overall, there was a greater chance of extension loss (p=0.007) and a trend towards increased patellofemoral joint pain (p=0.09) with a patella tendon graft. With a four-strand hamstring graft, there is a greater loss of hamstring power (p=0.008) and a trend towards an increased chance of a pivot shift >1 (p=0.12). There was no difference between the two groups in terms of Lachman testing, chance of returning to the same level of sport, clinical knee scores, graft ruptures or other complications.