# Comparison of patellar tendon and hamstring grafts in ACL reconstruction: patellar tendon shows lower re-rupture rates in high-risk groups and comparable patient-reported outcomes in lower-risk patients

## TL;DR

In ACL surgery, patellar tendon grafts had fewer re-ruptures in high-risk patients and similar outcomes in lower-risk patients compared to hamstring grafts.

## Contribution

Shows BTB grafts reduce re-rupture rates in high-risk ACL patients without compromising patient-reported outcomes.

## Key findings

- BTB grafts had significantly lower re-rupture rates in high-risk patients compared to HT grafts.
- In lower-risk patients, BTB and HT grafts showed similar re-rupture rates and clinical outcomes.
- Patient-reported outcomes (KOOS) were comparable between graft types in both risk groups.

## Abstract

To compare re-rupture rates and clinical outcomes between bone–patellar tendon–bone (BTB) and hamstring tendon (HT) grafts in anterior cruciate ligament (ACL) reconstruction according to patient risk levels.

This retrospective cohort study included patients who underwent primary ACL reconstruction at a single institution between 2018 and 2022, with outcomes assessed at a fixed 2-year postoperative follow-up. The primary endpoint was graft re-rupture, defined as a traumatic graft failure confirmed clinically and by magnetic resonance imaging, and the secondary endpoint was the Knee injury and Osteoarthritis Outcome Score (KOOS). High-risk status was defined as the presence of all three risk factors: age ≤ 20 years, posterior tibial slope. (PTS) ≥ 12°, and participation in pivoting sports. For patients with two or fewer risk factors, propensity score matching was performed using age, sex, body weight, generalized joint laxity, knee hyperextension, participation in pivoting sports, and PTS as covariates to compare outcomes between BTB and HT grafts.

In the high-risk group, the BTB graft showed a significantly lower re-rupture rate compared to the HT graft (12.9% vs. 35.7%, p = 0.03), with no significant difference in KOOS overall score (96.3 ± 3.7 vs. 96.6 ± 6.3, p = 0.85). In the lower-risk group after matching, the BTB graft showed a similar re-rupture rate compared to the HT graft (6.9% vs. 5.2%, p = 0.99), with no significant difference in KOOS overall score (92.6 ± 6.9 vs. 94.8 ± 5.7, p = 0.10).

BTB grafts reduced re-rupture rates compared to HT grafts in high-risk ACL reconstruction patients, while clinical outcomes were similar. In lower-risk patients, no significant differences were observed between graft types in either re-rupture rates or KOOS overall score.

Level III.

The online version contains supplementary material available at 10.1007/s00402-026-06196-5.