What tendon is typically used for anterior cruciate ligament (ACL) reconstruction in a patient with no significant medical history or allergies?

ACL Reconstruction Graft Selection

Both bone-patellar tendon-bone (BPTB) and hamstring tendon (HS) autografts are the two primary options for ACL reconstruction, with BPTB providing superior knee stability and lower graft failure rates, while HS grafts result in less anterior knee pain. 1

Primary Graft Options

The two standard autograft choices are:

• Bone-patellar tendon-bone (BPTB) - central third of patellar tendon with bone blocks 1
• Hamstring tendon (HS) - combined semitendinosus and gracilis tendons 1

Comparative Performance: BPTB vs Hamstring

Knee Stability (Favors BPTB)

• BPTB grafts consistently produce more statically stable knees across all objective measures 2
• Instrumental testing, Lachman, and pivot shift tests all demonstrate superior stability with BPTB 2
• BPTB results in 1.3-1.5 mm anterior knee laxity versus 2.4-2.5 mm with HS grafts at 1-2 years 3
• Rotational knee stability is significantly better with BPTB at nearly all time points 3

Graft Failure Risk (Favors BPTB)

• The American Academy of Orthopaedic Surgeons recognizes that BPTB autografts reduce graft failure risk compared to hamstring grafts 4, 5
• For high-demand athletes where maximum stability is critical, BPTB may be preferred due to lower graft failure rates 5

Anterior Knee Pain (Favors Hamstring)

• BPTB grafts increase anterior knee pain and kneeling pain compared to hamstring grafts 4, 2
• HS patients experience significantly less anterior knee pain in the first 6 months postoperatively 6
• At 2 years, hamstring grafts demonstrate less anterior knee pain than BPTB 3

Muscle Strength Deficits

• BPTB grafts result in loss of knee extension strength and extension range of motion 2
• HS grafts result in persistent hamstring torque deficits that may not recover even at 2 years postoperatively 3
• Hamstring patients show significant deficits in hamstring muscle torque at 90°/s and 230°/s 3

Return to Sport (Favors BPTB)

• Athletes with BPTB grafts return to sports earlier and at higher activity levels than those with HS grafts 3
• BPTB patients demonstrate higher Tegner activity scores at all time points except 1 year 3

Functional Outcomes (Equivalent)

• No significant differences exist between grafts for: 2, 7
  • Single leg hop test
  • Return to activity rates
  • Tegner and Lysholm scores
  • Subjective outcome measures
  • International Knee Documentation Committee scores
• Both grafts significantly improve clinical results and knee stability 6

Clinical Decision Algorithm

Choose BPTB when:

• Young, high-demand athletes requiring maximum knee stability 5
• Patients prioritizing lowest graft failure risk 4, 5
• Competitive athletes needing faster return to high-level sport 3
• Patients with occupations not requiring frequent kneeling 2

Choose Hamstring when:

• Patients with occupations requiring frequent kneeling (e.g., carpet layers, plumbers) 2
• Patients prioritizing minimal anterior knee pain 4, 6
• Recreational athletes with lower stability demands 3
• Patients concerned about extensor mechanism complications 4

Important Caveats

• Early reconstruction (within 3 months) is recommended regardless of graft choice to reduce risk of additional cartilage and meniscal injury 5, 8
• Rehabilitation protocols must be graft-specific: BPTB requires donor site protection strategies, while HS requires focused hamstring strengthening 4, 5
• The clinical significance of range of motion losses with either graft remains unclear 2
• Insufficient long-term data exists to assess osteoarthritis development differences between grafts 2
• Both single-bundle and double-bundle techniques show similar outcomes regardless of graft choice 5