Anatomic Anterior Cruciate Ligament Reconstruction via Independent Tunnel Drilling: A Systematic Review of Randomized Controlled Trials Comparing Patellar Tendon and Hamstring Autografts

Purpose To collect the highest level of evidence comparing anatomic anterior cruciate ligament (ACL) reconstruction via independent tunnel drilling using bone–patellar tendon–bone (BTB) and hamstring tendon (HT) autografts in terms of clinical outcome and failure rate. Methods We performed a systematic review of clinical trials that randomized patients to ACL reconstruction with either BTB or HT autografts with a minimum 2‐year follow‐up. Only trials using independent tunnel drilling, including outside‐in and anteromedial portal techniques, for both autografts were eligible for inclusion, whereas all transtibial studies were excluded. Study design, demographics, surgical technique, rehabilitation protocol, and clinical outcomes were compiled. Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines were followed. Quality assessment was performed using the Coleman Methodological Scale (CMS). Results Six published studies reporting on 5 randomized controlled trials (RCTs) met the inclusion criteria. No study reported a difference in rerupture rate between BTB and HT. BTB‐reconstructed knees experienced a greater incidence of anterior knee pain or crepitus in 2/7 trials and radiographic evidence of degenerative change in 3/7 trials. HT‐reconstructed knees had increased instrumented laxity in 2/7 trials and less knee flexion strength postoperatively. Conclusions This study collects all available Level I and II evidence for anatomic ACL reconstruction using BTB and HT grafts. According to the data presented in these studies, clinical outcome scores and failure rates showed no differences for anatomic reconstruction using either autograft. However, in some studies, BTB‐reconstructed knees experienced a greater incidence of anterior knee pain and radiographic evidence of degenerative change, and in others, HT‐reconstructed knees had increased laxity and less knee flexion strength. In our opinion, both BTB and HT autografts remain valid options for ACL reconstruction when using anatomic drilling techniques, providing a stable knee with reliable return to activity. Level of Evidence Level II, systematic review of Level I and II studies.