Long-term Results of Bone-Patellar Tendon-Bone Versus Hamstring Tendon Autograft for Primary Anterior Cruciate Ligament Reconstruction: A Meta-analysis of Randomized Controlled Trials

Background: Bone-patellar tendon-bone (BTB) and hamstring tendon (HT) autografts are the most commonly utilized grafts for primary anterior cruciate ligament reconstruction (ACLR). While previous studies have compared outcomes using BTB and HT grafts for ACLR at short- and mid-term follow-ups, outcomes at long-term follow-ups remain unclear. Purpose: To perform a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating BTB versus HT autografts for primary ACLR at a minimum 10-year follow-up. Study Design: Systematic review; Level of evidence, 2. Methods: A systematic review was performed in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by querying 5 databases from inception through May 2024 to identify level 1 and 2 RCTs evaluating outcomes of BTB versus HT autografts for primary ACLR at a minimum 10-year follow-up. A meta-analysis was performed using random-effects models with risk ratios (RRs) for discrete outcomes and mean differences (MDs) for continuous outcomes. Results: Six RCTs—consisting of 495 (BTB, n = 235; HT, n = 260) patients—were identified. The mean age at the follow-up was 41.3 ± 7.4 years, with men comprising 64% (n = 316/495) of patients. The mean final follow-up time was 14.6 ± 0.7 years (range, 10-17 years). No significant differences were observed in ACL graft rupture or revision rates (RR, 0.88; P =.70), contralateral ACL rupture rates (RR, 1.27; P =.46), Lysholm scores (MD, –1.27; P =.45), Tegner scores (MD, –0.01; P =.97), extension deficits (RR, 2.67; P =.23), or KT-1000 side-to-side differences (MD, –0.56; P =.10). There was a significantly greater risk of osteoarthritis (OA) progression in ACLR knees compared with the contralateral knee (RR, 3.64; P <.0001); however, there was no difference in OA progression between BTB and HT groups (RR, 1.01; P =.91). Conclusion: BTB and HT autografts for primary ACLR demonstrate similar outcomes and rates of OA progression at long-term follow-ups. Knees undergoing ACLR have a greater risk of OA progression compared with healthy contralateral knees.