A highly polarised debate has been raging for years regarding the best choice of graft in Anterior Cruciate Ligament Reconstruction (ACLR). There are strong advocates for either the hamstring or patella tendon technique, or for various versions of artificial ligaments.
Many surgeons recommend the same technique for all patients. In reality each patient has different needs and expectations and each technique has its own risks and benefits. I perform all of these techniques and discuss this choice with each patient I see with an anterior cruciate ligament injury.
If we look to the evidence, there are a number of major international studies and orthopaedic registries which detail complication rates for hamstring and patella tendon grafts in large numbers of patients.
The Anterior Cruciate Ligament Registries of Denmark (13,647 ACLRs), Norway (12,643 ACLRs) and the Kaiser Permanente Registry in the USA (9,817 ACLRs) show a 1.4 to 2.3 times higher failure rate in hamstring grafts compared to patella tendon grafts.
The Swedish registry however (13,102 ACLRs), and a Cochrane Review of 19 high quality scientific studies (1597 ACLRs), showed no difference in rupture rate. The Cochrane review also showed that patella tendon grafts have a higher rate of pain at the front of the knee when kneeling in comparison to hamstring grafts.
A reasonable conclusion is that hamstring tendon grafts fail more often than patella tendon grafts, but have less chance of pain when kneeling.
There is less available evidence for synthetic grafts. It is clear however that synthetic ligaments can enable an earlier return to sport at the expense of a significantly higher failure rate. The best evidence for this is the 2014 AFL Injury Report which showed that the failure rate of LARS synthetic ACL reconstructions in AFL players at three years was 50%! This has resulted in a dramatic reduction in the number of LARS ligaments being used.
When deciding on graft choice it is crucial to assess each individual's goals and expectations for returning to everyday life and activities.
Most patients will have a long-term view. If the priority is a stable knee with the least risk of rupture when returning to sport and general physical activity, then the best choice may be a patella tendon. If kneeling is especially important then the ideal choice may be a hamstring graft. For an athlete who targets a short-term return to sport to maintain their sporting career a LARS synthetic ligament may be a good option.
There is no 'one size fits all' technique. The best approach is to discuss the options with your surgeon and find the appropriate solution to suit your individual needs. This offers the best possible chance of a successful outcome.
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- Rahr-Wagner L1, Thillemann TM, Pedersen AB, Lind M.Comparison of hamstring tendon and patellar tendon grafts in anterior cruciate ligamentreconstruction in a nationwide population-based cohort study: results from the danish registry of knee ligament reconstruction. Am J Sports Med. 2014 Feb;42(2):278-84.
- Persson A1, Fjeldsgaard K, Gjertsen JE, Kjellsen AB, Engebretsen L, Hole RM, Fevang JM.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 CruciateLigament Registry, 2004-2012. Am J Sports Med. 2014 Feb;42(2):285-91.
- Andernord D1, Björnsson H2, Petzold M3, Eriksson BI2, Forssblad M4, Karlsson J2, Samuelsson K2. Surgical Predictors of Early Revision Surgery After Anterior Cruciate LigamentReconstruction: Results From the Swedish National Knee Ligament Register on 13,102 Patients. Am J Sports Med. 2014 Jul;42(7):1574-82.
- Maletis GB1, Inacio MC2, Funahashi TT3.Risk factors associated with revision and contralateral anterior cruciate ligament reconstructions in the Kaiser Permanente ACLR registry. Am J Sports Med. 2015 Mar;43(3):641-7.
- Mohtadi NG1, Chan DS, Dainty KN, Whelan DB.Patellar tendon versus hamstring tendon autograft for anterior cruciate ligament rupture in adults. Cochrane Database Syst Rev. 2011 Sep 7;(9)
- Orchard J, Seward H, Orchard J. AFL Injury Report: Season 2013. Secondary AFL Injury Report: Season 2013. AFL. 2014.