Original Research

Return to Sport After ACL Reconstruction With

a BTB Versus Hamstring Tendon Autograft
A Systematic Review and Meta-analysis
Matthew W. DeFazio,* MD, Emily J. Curry,†‡ MPH, Michael J. Gustin,* MD, David C. Sing,*‡ MD,
Hussein Abdul-Rassoul,* MD, Richard Ma,§ MD, Freddie Fu,k MD, and Xinning Li,*‡{ MD
Investigation performed at Boston University School of Medicine, Boston, Massachusetts, USA

Background: Anterior cruciate ligament (ACL) tears are debilitating injuries frequently suffered by athletes. ACL reconstruction is
indicated to restore knee stability and allow patients to return to prior levels of athletic performance. While existing literature
suggests that patient-reported outcomes are similar between bone–patellar tendon–bone (BTB) and hamstring tendon (HT)
autografts, there is less information comparing return-to-sport (RTS) rates between the 2 graft types.
Purpose: To compare RTS rates among athletes undergoing primary ACL reconstruction using a BTB versus HT autograft.
Study Design: Systematic review; Level of evidence, 4.
Methods: The MEDLINE, Embase, and Cochrane Library databases were searched, and studies that reported on RTS after
primary ACL reconstruction using a BTB or HT autograft were included. Studies that utilized ACL repair techniques, quadriceps
tendon autografts, graft augmentation, double-bundle autografts, allografts, or revision ACL reconstruction were excluded. RTS
information was extracted and analyzed from all included studies.
Results: Included in the review were 20 articles investigating a total of 2348 athletes. The overall RTS rate in our cohort was 73.2%,
with 48.9% returning to preinjury levels of performance and a rerupture rate of 2.4%. The overall RTS rate in patients after primary
ACL reconstruction with a BTB autograft was 81.0%, with 50.0% of athletes returning to preinjury levels of performance and a
rerupture rate of 2.2%. Patients after primary ACL reconstruction with an HT autograft had an overall RTS rate of 70.6%, with
48.5% of athletes returning to preinjury levels of performance and a rerupture rate of 2.5%.
Conclusion: ACL reconstruction using BTB autografts demonstrated higher overall RTS rates when compared with HT autografts.
However, BTB and HT autografts had similar rates of return to preinjury levels of performance and rerupture rates. Less than half of
the athletes were able to return to preinjury sport levels after ACL reconstruction with either an HT or BTB autograft.
Keywords: bone–patellar tendon–bone autograft; hamstring tendon autograft; allograft; return to sport; anterior cruciate ligament
rupture; anterior cruciate ligament reconstruction

Anterior cruciate ligament (ACL) tears or ruptures are one emerging along with different options for graft choices,18
of the most common knee injuries seen in an athletic popula- surgical reconstruction of the ACL using autografts in young
tion. The exact number of ACL reconstruction procedures athletes remains the standard of care. However, autograft
performed in the United States is unknown; however, Her- selection is still an ongoing topic of debate in the sport med-
zog et al,22 using the MarketScan database with approxi- icine literature and among orthopaedic sports medicine
mately 158 million privately insured patients, reported surgeons.
that 283,810 ACL reconstruction procedures were performed The most commonly used autografts are (1) bone–patellar
between 2002 and 2014. The overall rate increased 22% from tendon–bone (BTB) grafts harvested typically from the mid-
61.4 per 100,000 person-years in 2002 to 74.6 per 100,000 dle third of the ipsilateral patellar tendon or (2) hamstring
person-years in 2014. An ACL tear is a devastating, season- tendon (HT) grafts harvested from the semitendinosus and
ending injury, with only 51% of athletes returning to sport gracilis tendons. There are advantages and disadvantages
without restrictions at 6 months postoperatively.12,21 While as well as morbidity associated with each of these autograft
methods describing the repair of a ruptured ACL are options. Compared with patients receiving HT autografts,
those who receive BTB autografts may experience more
The Orthopaedic Journal of Sports Medicine, 8(12), 2325967120964919
anterior knee pain resulting from donor site pain and a
DOI: 10.1177/2325967120964919 larger incision at the time of harvest as well as possible
ª The Author(s) 2020 extensor strength deficits.20,41,46,55 In comparison, HT

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1
2 DeFazio et al The Orthopaedic Journal of Sports Medicine

autografts have been associated with prolonged hamstring reconstruction) or (ACL tear) or (anterior cruciate ligament
or knee flexion weakness, saphenous nerve damage, and tear) or (Bone Patella Tendon Bone) or (hamstring) or
sensory loss.8,20,28 The HT autograft may also be suscepti- (BTB) AND ((return to sports) or (return to preinjury activ-
ble to stretching over time, weakening its ability to main- ity) or (athlete) or (athletics) or (athletic population) or (ath-
tain objective rotational stability of the knee lete population) or (return to competition) or (return to
postoperatively. athletics))). In order to maximize sensitivity, no filters were
The primary goal of ACL reconstruction in the young applied.
athletic population is to stabilize the knee for returning to
prior levels of sport participation. While the literature sug-
gests that there are no major differences between BTB and Eligibility Criteria
HT autografts with respect to clinical outcomes,9,49 less
information exists comparing the rate of return to sport All search results were extracted and examined for rele-
(RTS) between these 2 graft types. A study by Mascarenhas vance, and duplicate articles were discarded. Titles and
et al35 found that 70% of young athletes who had either a abstracts were then screened for relevance. Bibliographies
BTB or HT autograft were able to return to strenuous or of relevant articles were also manually searched to find
very strenuous sporting activity. However, only 57% of other pertinent articles that were screened out of the
patients with a BTB autograft and 44% of patients with database algorithms. Articles were filtered based on the
an HT autograft were able to return to preinjury levels of following exclusion criteria: (1) non-English text, (2) not
performance. A 2018 systematic review also found that athlete-specific population, (3) only abstract available, (4)
while the majority of elite athletes return to their prior did not quantify RTS outcomes, (5) treatment was nonsur-
level of sport, performance declines in comparison with pre- gical or did not specify which graft (HT or BTB) was used,
injury levels. Furthermore, the authors found limited avail- (6) studies included multiple treatments without stratify-
able literature on RTS after ACL reconstruction in terms of ing by operation type, (7) surgical treatment was on skele-
sport-specific performance after ACL surgery.37 Therefore, tally immature patients, (8) patients were treated with
determining which autograft type provides superior RTS allografts, (9) studies were on revision ACL reconstruction,
may aid surgeons and patients in shared decision making (10) review articles or meta-analyses, and (11) case reports.
and setting of expectations for both functional outcomes We made the decision to include non–randomized con-
and expected RTS rates after ACL reconstruction. The trolled trials for this meta-analysis because of the scarcity
objective of this systematic review and meta-analysis was of published randomized controlled trials available for this
to compare the rates of overall RTS, return to preinjury topic. Only studies that included RTS rates centering on a
levels, and reruptures between athletes who have under- single surgical procedure, or studies that specifically strat-
gone primary ACL reconstruction using a BTB versus ified mixed patient populations or surgical treatments,
HT autograft. were evaluated. Because of the limited RTS data after ACL
reconstruction with double-bundle HT grafts, the decision
was made to include only primary ACL reconstruction with
METHODS single-bundle HT autografts in this analysis. Of note, there
were 2 studies conducted by Ardern et al3,5 that utilized the
Search Strategy same cohort at 2 different follow-up periods, and only the
more recent study with longer follow-up, published in 2012,
A systematic search strategy was developed according to was included in our final analysis.3
the PRISMA (Preferred Reporting Items for Systematic
Reviews and Meta-Analyses) guidelines.36 The goal of the
search was to identify articles that report on RTS after Article Review
primary ACL reconstruction with an autograft. A search
of electronic databases was performed to find potentially After the screening phase, all eligible articles were evalu-
relevant research articles reporting on RTS after ACL ated for inclusion criteria and relevant data on RTS and
reconstruction. The MEDLINE (PubMed), Embase (Else- outcomes after ACL reconstruction. All articles were
vier), and Cochrane Library databases were searched in reviewed, assessed, and data-mined by 2 independent eval-
October 2018 using the following Boolean search terms: uators (M.D. and M.J.G.). All results were then compared
(((ACL reconstruction) or (anterior cruciate ligament to ensure consistency and accuracy. Any conflicts or issues

{
Address correspondence to Xinning Li, MD, Department of Orthopaedic Surgery, Boston University School of Medicine, 850 Harrison Avenue, Dowling 2
North, Boston, MA 02118, USA (email: [email protected]) (Twitter: @TigerLiMD).
*Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, Massachusetts, USA.
†
Boston University School of Public Health, Boston, Massachusetts, USA.
‡
Boston Medical Center, Boston, Massachusetts, USA.
§
Missouri Orthopaedic Institute, Columbia, Missouri, USA.
k
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
Final revision submitted May 23, 2020; accepted June 15, 2020.
One or more of the authors has declared the following potential conflict of interest or source of funding: X.L. has received consulting fees from DePuy and
hospitality payments from Stryker and Tornier. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted
an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
The Orthopaedic Journal of Sports Medicine Return to Sport: BTB Versus Hamstring Tendon Graft 3

were resolved by a review of the articles, and the senior autografts. Appendix Table A1 shows the type of sport
author (X.L.) made the final determination. played, concomitant procedures, and revision surgery for
ACL reconstruction with BTB autografts. In the HT group,
Data Extraction and Assessment there was one level 5 study, 38 six level 4 stud-
ies,10,29,31,33,40,52 six level 3 studies,3,11,17,19,35,43 one level 2
Articles that met inclusion criteria were analyzed for qual- study,48 and four level 1 studies14,26,34,47 (Table 2). Table 2
ity, and data to be used in the review were extracted. The shows the demographic and RTS data after primary ACL
following items were extracted from the included articles: reconstruction with HT autografts. Appendix Table A2
author, publication year, journal title, level of evidence, shows the type of sport played, concomitant procedures, and
study design, surgical procedure, number of athletes, type revision surgery for ACL reconstruction with HT autografts.
of sport, number of participants per sport type, level of ath- There were 2 studies that reported the RTS rate for BTB
letic participation, mean age at the time of surgery, sex, grafts but not the rate of return to preinjury levels,10,43 and
mean follow-up period, concomitant procedures, percentage 2 studies only reported the rate of return to preinjury levels
of athletes who returned to sport, percentage of athletes but not the rate of RTS overall.16,48 There were 5 studies
who returned to preinjury levels of sport, and subsequent that reported on RTS for HT grafts but did not comment on
procedures needed. Studies including multiple graft types return to prior levels of sport participation.10,11,29,38,43 In 3
were stratified and analyzed by graft type independently. of the studies, only return to prior levels of play was
reported, but overall RTS was not reported.17,31,48
Quality Assessment Overall, there were 9 studies that reported RTS data for
both BTB and single-bundle HT autografts,# 2 studies that
To assess the quality of each case series study that was reported RTS data for BTB autografts only without HT
included in the analysis, the Risk of Bias in Non- grafts as a comparison group, 16,25 and 9 studies that
Randomized Studies of Interventions (ROBINS-I) tool was reported RTS data for HT autografts only without BTB
utilized.50 This risk-of-bias tool includes 7 criteria: (1) bias grafts as a comparison group.** Moreover, 8 of the 9 studies
due to confounding, (2) bias in selection of participants into directly comparing BTB versus HT autografts reported on
the study, (3) bias in classification of interventions, (4) bias the rate of RTS, with none finding a statistically significant
due to deviations from intended interventions, (5) bias due difference in RTS between grafts in their
to missing data, (6) bias in measurement of outcomes, and cohorts. 10,14,19,26,33,35,43,47 Further, 7 of the 9 studies
(7) bias in selection of the reported result. Each criterion reported on return to preinjury levels14,19,26,33,35,47,48; no
was rated as low risk, moderate risk, serious risk, or critical statistically significant difference in the rate of return to
risk in accordance with the ROBINS-I tool.47 preinjury levels was found in any study.

Statistical Analysis
Pooled Analysis
Studies that reported the rates of RTS, return to preinjury
A total of 2348 patient-athletes who underwent ACL recon-
levels of play, and reruptures for both BTB and HT grafts
struction were included in the studies reviewed, of which
were included in the meta-analysis. The meta-analysis was
610 patients received BTB autografts and 1738 patients
conducted using R V 3.5.2 (The R Foundation) and format-
received HT autografts (single-bundle). The pooled RTS
ted with Review Manager 5 (RevMan; Cochrane Collabora-
data are summarized in Table 3. All included studies
tion). This package summarized data to create appropriate
reported a minimum mean follow-up of 1 year.
forest plots for graphical presentation. A random-effects
Studies examining RTS after ACL reconstruction with
model was used to reduce bias from the potential system-
BTB grafts demonstrated a range of rates from 69% to
atic errors of the included studies, and the inverse variance
94%, with a mean rate of 81.0% for all patients. However,
method was used for the weighting of each study. Continu-
only 50.0% of all patients were able to return to their prior
ity correction of 0.5 was used in studies with zero cell fre-
level of play.
quencies. Homogeneity across the studies was assessed and
The studies that reported on RTS after ACL reconstruc-
represented by I 2 , with P < .05 being statistically
significant. tion with HT grafts showed a wider range of rates, from
48% to 93%, with a mean rate of 70.6% for all patients.
Across studies, 48.5% of patients returned to their prior
level of sport participation.
RESULTS In subgroup analyses of the level 1 and 2 studies for BTB
Individual Study Characteristics and HT autografts included in this review, the results
remained consistent with whole-group pooled analysis. In
A total of 20 studies met inclusion criteria and were included the BTB group (4 studies14,26,47,48), the rates of RTS and
in the final analysis (Figure 1). In terms of levels of evidence, return to preinjury sport levels were 81.8% and 57.1%,
in the BTB group, there were two level 4 studies,10,33 five respectively. In the HT group (5 studies14,26,34,47,48), the
level 3 studies,16,19,25,35,43 one level 2 study,48 and three level
1 studies14,26,47 (Table 1). Table 1 shows the demographic #
References 10, 14, 19, 26, 33, 35, 43, 47, 48.
and RTS data after primary ACL reconstruction with BTB **References 3, 11, 17, 29, 31, 34, 38, 40, 52.
4 DeFazio et al The Orthopaedic Journal of Sports Medicine

Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow chart indicating research article
inclusion for final analysis. MCL, medial collateral ligament; PCL, posterior cruciate ligament.

rates of RTS and return to preinjury levels of sport were return to preinjury levels of play, 14,19,26,33,35,47,48
74.8% and 52.7%, respectively. and 3 studies for ACL reruptures.14,19,47 The relative risks
of developing an unfavorable outcome after ACL recon-
Quality Assessment struction with BTB grafts compared with HT grafts were
as follows: inability to return to sport: 0.85 (95% CI, 0.55-
The risk-of-bias assessment is summarized in Table 4 and 1.32); inability to return to preinjury levels of play: 0.98
Figure 2. Of the 16 assessed studies, 15 studies had serious (95% CI, 0.82-1.16); and ACL reruptures: 0.67 (95% CI,
or moderate bias due to confounding factors such as differ- 0.12-3.60) (Figures 3-5). No statistical significance was
ing concomitant injuries/procedures, levels of competition, detected. The I2 index of homogeneity was 0% for 3 of 3
or sports played. Also, 5 of the 16 included studies had some meta-analyses, suggesting that the included studies were
risk of bias owing to missing data, specifically from patients homogeneous; however, this may also represent that all
lost to follow-up. Furthermore, all studies had some risk of studies were underpowered to detect a difference in
bias in terms of outcome measures, as RTS is often a sub- outcomes.
jective measure. A limitation with several of these studies
was that they reported RTS data based on graft type but did
not separate the patient demographic data for each individ- DISCUSSION
ual graft type during the analysis.10,33,43
The overall rate of RTS was 73.2%, but the BTB group had
Meta-analysis a 10.4% higher overall rate of RTS (81.0%) compared with
the HT group (70.6%). Importantly, these findings were
Of the 20 studies identified for the systematic review, the consistent with our subanalysis of RTS rates from level 1
following subset of studies evaluated outcomes for both BTB and 2 studies only, with BTB and HT autografts demon-
and HT grafts: 5 studies for RTS,10,14,26,35,47 7 studies for strating RTS rates of 81.8% and 74.8%, respectively.
The Orthopaedic Journal of Sports Medicine Return to Sport: BTB Versus Hamstring Tendon Graft 5

TABLE 1
Demographic and RTS Data for Studies With BTB Autograftsa

First Author No. of Age at Follow-up, RTS Rate, Rate of Return to Rerupture
(Year) LOE Athletes Surgery, y M:F Sex, n mo % (n) Preinjury Levels, % (n) Rate, % (n)

Gobbi16 (2002) 3 40 25 26:14 46 (36-62) NR 60 (24/40) 0 (0/40)

Shaieb47 1 33 32 (14-48) 26:7 >24 88 (29/33) 55 (18/33) 6 (2/33)
(2002)b
Feller14 (2003)b 1 26 25.8 ± 6 NR 36 69 (18/26) 54 (14/26) 4 (1/27)
Jennings25 3 50 30 (17-51) 32:18 62 (48-95) 94 (47/50) 32 (16/50) 0 (0/50)
(2003)
Mascarenhas35 3 23 18 ± 3 10:13 60 ± 24 74 (17/23) 57 (13/23) NR
(2012)b
Daruwalla10 4 140 NR 140:0 >12 84 (117/140) NR NR
(2014)b
Kautzner26 1 39 NR 0:39 24 87 (34/39) 49 (19/39) 5 (2/39)
(2015)b
Sandon43 3 22 NR NR NR 73 (16/22) NR NR
(2015)b
Sonnery- 2 85 22 ± 4 NR 39.2 ± 8.8 (24-54) NR 64 (54/85) NR
Cottet48
(2017)b
Liptak33 4 72 NR 72:0 NR 72 (52/72) 45 (19/42) NR
(2017)b
Gupta19 3 80 24 (18-44) 74:6 61.1 ± 25.8 79 (63/80) 40 (32/80) 1 (1/80)
(2018)b
a
Data are presented as mean, mean ± SD, mean (range), or mean ± SD (range) unless otherwise specified. BTB, bone–patellar tendon–
bone; F, female; LOE, level of evidence; M, male; NR, not reported; RTS, return to sport.
b
Study compared BTB and hamstring tendon (HT) grafts.

TABLE 2
Demographic and RTS Data for Studies With HT Autograftsa
First Author No. of Age a Rate of Return to Rerupture
(Year) LOE Graft Type Athletes Surgery, y M:F Sex, n Follow-up, mo RTS Rate, % (n) Preinjury Levels, % (n) Rate, % (n)

Shaieb47 (2002)b 1 STG (4-strand) 37 30 (14-53) 21:16 24 91 (32/35) 63 (22/35) 5 (2/37)

Gobbi17 (2003) 3 ST (4-strand plus bone 80 28 52:28 36 (24-52) NR 65 (52/80) 1 (1/80)
block [Fastlok
fixation])
Feller14 (2003)b 1 STG 34 26.3 ± 6 24:10 36 50 (17/34) 47 (16/34) 0 (0/34)
Lee31 (2008) 4 STG (double-looped) 45 24.8 (18-40) NR 60 NR 62 (28/45) NR
Ardern3 (2012) 3 STG (4-strand) 314 32.5 ± 10.2 183:131 39.6 ± 13.8 66 (208/314) 45 (140/314) NR
Mascarenhas35 (2012)b 3 STG (4-strand) 23 18 ± 3 10:13 48 ± 24 70 (16/23) 43 (10/23) NR
Daruwalla10 (2014)b 4 NR 15 NR 15:0 >12 93 (14/15) NR NR
Kyung29 (2015) 4 ST (4-strand) 144 29 ± 11.3 144:0 26.9 ± 4.4 83 (120/144) NR NR
Sandon43 (2015)b 3 NR 183 NR NR NR 52 (95/183) NR NR
Kautzner26 (2015)b 1 NR 42 NR 0:42 24 90 (38/42) 62 (26/42) 0 (0/42)
Rodriguez-Roiz40 (2015) 4 NR 99 30 (14-52) 74:25 36 91 (90/99) 52 (51/99) NR
Liu34 (2016) 1 STG (3- or 4-strand) 34 29.7 (17-47) NR 80.8 (75-86) 68 (23/34) 9 (3/34) 0 (0/34)
Notarnicola38 (2016) 5 STG 80 29.7 ± 8.4 74:6 13 ± 2 48 (38/80) NR NR
Sonnery-Cottet48 (2017)b 2 STG (4-strand) 147 23.5 ± 4.0 NR 38.4 ± 8.5 (24-54) NR 60 (88/147) NR
Webster52 (2017) 4 NR 140 17.2 ± 1.3 82:58 61.2 (36-84) 76 (107/140) 50 (70/140) NR
Liptak33 (2017)b 4 NR 39 NR 39:0 NR 77 (30/39) 54 (14/26) NR
Gupta19 (2018)b 3 STG 169 23.5 (16-46) 153:16 62.18 ± 25.9 79 (133/169) 33 (56/169) 4 (7/169)
Edwards11 (2018) 3 NR 113 25.9 ± 7.1 75:38 12 (10-14) 64 (72/113) NR NR

a
Data are presented as mean, mean ± SD, mean (range), or mean ± SD (range) unless otherwise specified. F, female; HT, hamstring tendon;
LOE, level of evidence; M, male; NR, not reported; RTS, return to sport; ST, semitendinosus; STG, semitendinosus/gracilis.
b
Study compared bone–patellar tendon–bone (BTB) and HT grafts.

When evaluating return to preinjury levels of sport, the groups (50.0% BTB vs 48.5% HT). Results of our subanal-
pooled rate of return was 24.3% lower (48.9%) than the ysis of return to preinjury levels in level 1 and 2 studies
overall RTS rate (73.2%). However, the rate of return to (57.1% BTB and 52.7% HT), while slightly higher than our
preinjury levels was very similar between autograft pooled results, once again demonstrated a similar
6 DeFazio et al The Orthopaedic Journal of Sports Medicine

TABLE 3
Pooled Demographic and RTS Data by Graft Typea

No. of No. of Mean Age at Mean RTS Rate, Rate of Return to Preinjury Rerupture Rate,
Graft Athletes Studies Surgery, y Follow-up, mo % (n) Levels, % (n) % (n)

BTB 610 11 25.0 36.6 81.0 (393/485) 50.0 (209/418) 2.2 (6/269)
HT 1738 18 23.1 39.4 70.6 (1033/1464) 48.5 (576/1188) 2.5 (10/396)
Overall 2348 20 23.6 38.7 73.1 (1426/1952) 48.9 (785/1606) 2.4 (16/665)
a
BTB, bone–patellar tendon–bone; HT, hamstring tendon; RTS, return to sport.

TABLE 4
Risk-of-Bias Assessment for Observational Studies

Bias in
Bias in Selection of Bias in Bias due to Deviations Bias due to Bias in Selection of
First Author Bias due to Participants Into Classification of From Intended Missing Measurement Reported
(Year) Confounding Study Interventions Interventions Data of Outcomes Result

Gobbi16 (2002) Serious Moderate Low Low Low Moderate Moderate

Gobbi17 (2003) Serious Moderate Low Low Low Moderate Moderate
Jennings25 Serious Low Low Low Low Moderate Moderate
(2003)
Lee31 (2008) Serious Serious Low Low Low Moderate Moderate
Ardern3 (2012) Serious Moderate Low Low Serious Moderate Moderate
Mascarenhas35 Serious Moderate Low Low Low Moderate Moderate
(2012)
Daruwalla10 Serious Serious Low Low Serious Moderate Serious
(2014)
Kyung29 (2015) Serious Serious Low Low Serious Moderate Serious
Sandon43 Moderate Moderate Low Low Serious Moderate Serious
(2015)
Rodriguez- Serious Serious Low Low Low Moderate Serious
Roiz40 (2015)
Notarnicola38 Moderate Low Low Low Low Moderate Moderate
(2016)
Sonnery- Low Low Low Low Low Moderate Moderate
Cottet48
(2017)
Webster52 Serious Serious Low Low Serious Moderate Serious
(2017)
Liptak33 (2017) Moderate Low Low Low Low Moderate Moderate
Gupta19 (2018) Moderate Moderate Low Low Low Moderate Serious
Edwards11 Moderate Low Low Low Low Moderate Moderate
(2018)

pattern. Furthermore, we found the overall rerupture autograft reconstruction.6 In a recent systematic review,
rate to be 2.4%, with relatively similar rates in the BTB Wasserstein et al51 found that the pooled failure rate for
group (2.2%) and the HT group (2.5%). To our knowledge, allografts was 25% compared with the autograft failure
this is the first systematic review and meta-analysis rate of 9.6% in patients aged <25 years. However, when
directly comparing primary ACL reconstruction with BTB comparing autograft options, the current literature
and HT autografts and sport-related outcomes (RTS and remains mixed in terms of reporting which autograft
return to preinjury levels of play). choice is optimal for competitive athletes to increase their
There remains a lack of consensus on which ACL graft RTS rate. As the 2 most common autograft options, BTB
choice will optimize RTS for athletes at the highest level of and HT grafts have been the topic of much debate with
competition, with surgeon preference continuing to play a regard to which graft is superior, leading to numerous
considerable role in graft selection. 24 It is generally comparative studies.26,27,29,35,42,45 While the subjective
accepted that autografts are the appropriate graft of patient-reported outcomes for both BTB and HT auto-
choice for young (<25 years of age), high-demand athletes grafts overall are thought to be similar, some authors have
because the reported failure rates for allograft reconstruc- advocated for the use of BTB autografts for the documen-
tion in these patients is up to 3 times higher than for ted better objective stability and lack of stretching that
The Orthopaedic Journal of Sports Medicine Return to Sport: BTB Versus Hamstring Tendon Graft 7

Figure 2. Risk of bias assessment for included studies, with green representing a low risk of bias for a given criteria, yellow
indicating a moderate risk of bias, and red indicating a serious risk of bias.

Figure 3. Assessment of risk of inability to return to sport with bone–patellar tendon–bone (BTB) grafts compared with hamstring
tendon (HT) grafts. IV, inverse variance.

can be seen when compared with HT autografts.27,45,55 and intensive rehabilitation. These factors, along with
Additional studies have shown that HT autografts are superior levels of motivation, physical fitness, talent,
associated with prolonged hamstring weakness in knee resources, and financial incentive to return to elite play,
flexion as well as sensory loss resulting from saphenous may contribute to the higher rates of return to preinjury
nerve damage.8,20,28,41,55 Conversely, some surgeons avoid levels noted in this study of professional athletes.33 Another
BTB autografts because of higher reported rates of persis- study by Ardern et al2 reported higher rates of return to
tent anterior knee pain and prefer HT autografts in an play in a nonelite patient population. However, their
effort to reduce morbidity related to graft harvest.20,41,55 results may be confounded by heterogeneity in the sporting
Our pooled rate of RTS was 73.2%, similar to reported demographics. Rodriguez-Roiz et al40 found that patients
rates of 81% to 83% in previous meta-analyses.2,4,30 The who participated in sports that required more cutting and
slightly lower rate may be attributable to patient demo- pivoting were less likely to return to preinjury levels of
graphics or the type of sport reported within the studies play. A number of the studies included in the current
that we reviewed. The meta-analysis by Lai et al30 reported review prominently featured athletes in sports with a high
the highest rate of RTS, with 83% of patients returning degree of cutting, pivoting, and contact such as rugby, soc-
after primary ACL reconstruction in a population of elite cer, football, and basketball, although incomplete reporting
athletes who likely had access to a high level of medical care of such data in some studies made precise quantification
8 DeFazio et al The Orthopaedic Journal of Sports Medicine

Figure 4. Assessment of risk of inability to return to preinjury levels with bone–patellar tendon–bone (BTB) grafts compared with
hamstring tendon (HT) grafts. IV, inverse variance.

Figure 5. Assessment of risk of reruptures with bone–patellar tendon–bone (BTB) grafts compared with hamstring tendon (HT)
grafts. ACL, anterior cruciate ligament; IV, inverse variance.

difficult. Further support for this explanation comes from a knee in contact sports.7,13,48 For this reason, the patients
recent systematic review by Mohtadi and Chan37 that with BTB autografts in our review may be representative of
found that only 63% of National Football League players a more athletic population than those receiving HT auto-
returned after ACL reconstruction, while up to 97% of grafts and therefore are more likely to return to sport
National Hockey League players returned after the same because of financial reasons, motivation, ability, and schol-
injuries. arship. In contrast, Ardern et al2 reported an RTS rate of
While our systematic review demonstrated an overall 83% for BTB autografts compared with 89% for HT auto-
RTS rate among athletes with BTB autografts (81.0%) that grafts; however, their review did not stratify the level of
is in line with the existing literature, the RTS rate for sport or type of sport played when reporting on RTS by
patients with HT autografts (70.6%) was found to be lower graft type. It is difficult to determine whether this or other
than previously reported. Furthermore, the range of factors played a role in the observed discrepancy between
reported RTS rates was more precise for the BTB group our findings and those of others.
than the HT group (69%-94% vs 48%-93%, respectively). It is important to separate RTS from return to preinjury
BTB autografts have historically been considered to have levels of sport when discussing the outcomes of athletes.
lower revision rates and higher postoperative stability in For example, in professional athletes, it is not uncommon
comparison with HT autografts and may be preferable in that athletes return to the professional level but not to pre-
competitive high-level athletes requiring pivot shift of the injury levels.37 Similarly to the pooled RTS data, the overall
The Orthopaedic Journal of Sports Medicine Return to Sport: BTB Versus Hamstring Tendon Graft 9

rate of return to preinjury levels of sport (48.9%) for both sport within the BTB group (27% BTB vs 47% HT), while
BTB and HT autografts in our systematic review was lower Xie et al55 found that BTB autografts performed signifi-
than that in recent meta-analyses by Ardern et al,2,4 which cantly better, with 60.5% of patients returning to preinjury
reported a range of 63% to 65% returning to preinjury activity levels compared with 51.1% with HT autografts.
levels. A meta-analysis by Xie et al55 reported a 55.6% rate Despite similar functional outcomes for both graft types,
of return to preinjury activity levels over 8 studies and 507 Xie et al suggested that BTB autografts be used in young
patients. Gabler et al15 found a pooled rate of return to and high-demand athletes to enable a greater proportion of
preinjury activity levels of 71.7% over 5 studies, although patients to return to their preinjury sport postoperatively
4 of these examined HT autografts only. It is possible that with higher levels of activity. The difference in the RTS
our lower rates of return to preinjury levels can be rates between BTB and HT autografts as reported in these
explained by our stricter inclusion criteria regarding studies is likely a result of the heterogeneity in the patient
athletic-specific populations. Previous studies may have population, type of sport, difference in demographics, and
included more nonathletic general patient populations that time of follow-up, among other factors.
require a lesser degree of functional capacity to return to The pooled rate of graft reruptures overall was 2.4% in
preinjury activity levels. our systematic review. This is within the range of previous
Rates of return to preinjury levels of play were similar studies, with pooled rerupture rates ranging from 2.8% to
between the 2 autograft groups (50.0% BTB vs 48.5% HT) in 6.4%.39,42,44,54,55 There was a similar rerupture rate with
our review of the literature, but the range of rates of return BTB autografts (2.2%) when compared with HT autografts
to preinjury levels was smaller for the BTB group (32%-64% (2.5%) in our review. However, it is important to note that a
BTB vs 9%-68% HT). This is interesting given the RTS large percentage of articles included in this review did not
data, as one might expect BTB grafts to follow the same report on rerupture rates. Because we found that there was
trend and have a higher rate of return to preinjury sporting a lower RTS rate in the HT group, it is possible that the
levels. One possible explanation is that, while patients with rerupture rate was higher than reported in the HT group
BTB grafts returned to sport at a higher rate because of the compared with the BTB group, but it was not reported in
potential bias toward using BTB grafts in athletes with the original study. In a level 2 cohort study by Persson
higher demands, once patients return to sport, the grafts et al39 that reported an overall rerupture rate of 4.2%, there
are about equally as effective in allowing patients to return was a significantly higher rerupture rate with HT grafts
to their preinjury level. There are many other factors (4%) compared with BTB grafts (2%). The decreased rerup-
involved in return to preinjury sport levels, including psy- ture rate with BTB autografts could be explained by both
chological factors and confidence in the reconstructed knee the increased objective stability of this graft and the trend
as well as the motivation of the athlete and intensity of the toward the use of BTB grafts in higher level athletes, who
postoperative rehabilitation protocol.53 Similar to our find- may benefit from more rigorous physical therapy and reha-
ings, Lindanger et al32 reported the long-term outcomes bilitation protocols. It is important to note that in our sys-
(25-year follow-up) of returning to pivot sports after pri- tematic review, the mean age of patients in the HT group
mary ACL reconstruction with BTB autografts and found was 2 years younger than that in the BTB group. As youn-
that 83% of the athletes were able to return to sport, but ger age is also a predictor of higher graft failure rates, this
only 53% returned to preinjury levels. Additionally, the may have biased our results and may explain the higher
incidence of contralateral ACL injuries was 28% among the rate of subsequent ACL injuries noted in the HT group
athletes who returned to sport versus 4% among the ath- compared with the BTB group.23,44 Our meta-analysis sug-
letes who did not return. The authors concluded that “ACL gested similar rates of RTS, return to preinjury levels of
reconstruction does not necessarily enable an athlete a play, and reruptures between the 2 autograft groups. Xie
return to preinjury sports participation.” Webster et al53 et al,55 in a meta-analysis of outcomes after ACL recon-
reported that only 61% (135/222) of patients were able to struction with BTB versus HT autografts, also reported
return to their preinjury levels of performance, with similar similar rerupture rates between BTB and HT autografts
rates between male and female patients. In the patients and objective International Knee Documentation Commit-
who returned to preinjury sports, the authors found that tee scores; however, the BTB group had better rotational
higher psychological readiness, greater limb symmetry, stability and returned to higher levels of activity compared
higher subjective knee scores, and a higher activity level with the HT group. Additionally, Samuelsen et al42 in their
were all associated with returning to sport at the preinjury meta-analysis reported no significant difference in rerup-
level. Our systematic review found that regardless of the ture rates and instrumented laxity between BTB and HT
graft type, less than half of the athletes ever returned to grafts (2.8% and 2.84%, respectively).
sport at the preinjury level after primary ACL reconstruc- There are limitations to consider when interpreting the
tion. There are many other factors that play into successful results of our systematic review. The majority of the arti-
RTS, especially returning to the preinjury level. This infor- cles in this review were extracted from level 3 and 4 evi-
mation is important to know and useful when counseling dence, representing a paucity of high-quality data
athletes regarding postoperative expectations and RTS. available, and indicate a call for higher level studies on this
There is also disagreement in the available literature topic. We used the ROBINS-I tool to assess bias in these
regarding return to preinjury levels between BTB and HT instances to evaluate these studies explicitly.50 This tool
autografts. Ardern et al2 reported that a lower proportion of was felt to be most appropriate to our systematic review,
patients returned to their preinjury competitive level of as it is applicable to both randomized and nonrandomized
10 DeFazio et al The Orthopaedic Journal of Sports Medicine

trials and offers many well-delineated criteria, each com- systematic review, so as to report appropriate and clinically
posed of discrete subcriteria on which to judge bias. This relevant numbers.
level of detail in evaluating studies and the use of categor-
ical risk classifications are important in light of the inclu-
sion of lower level studies. Other methodological quality CONCLUSION
assessments were deemed less appropriate, as they would
have been less able to distinguish between the studies; This systematic review and meta-analysis evaluated and
these include the Jadad score, which weights blinding synthesized RTS and return to preinjury sport levels after
greatly and has few additional distinguishing criteria, or primary ACL reconstruction using a BTB or HT autograft
the Coleman score, which does not offer categorical risk exclusively in athletes participating in sports from a recre-
classifications and relies heavily on outcome and rehabili- ational to professional level. Our study found that BTB
tation criteria that are widely variable within this topic and autografts yielded a higher overall RTS rate compared with
would therefore be improper to compare across the included HT autografts (81.0% vs 70.6%, respectively), while the
studies. rates of return to preinjury levels were similar between the
As most studies involved were retrospective in nature, 2 groups (50.0% vs 48.5%, respectively), as were the rerup-
there was a high risk of selection bias seen in these studies ture rates (2.2% vs 2.5%, respectively). While our RTS rate
focusing on an athletic population. Furthermore, there was for BTB autografts in athletes was similar to rates found in
heterogeneity in terms of patient age, sex ratio, level of previous meta-analyses that were not explicitly exclusive of
competition, and follow-up time, all of which can have an nonathletes, the RTS rate with HT grafts in this study was
impact on reported rates of RTS and return to preinjury lower than what has been reported previously. We also
levels. Another challenge was that physical therapy proto- found a lower rate of return to preinjury levels for both BTB
cols change from institution to institution and also change and HT autografts compared with the literature. Our find-
over time; therefore, studies that are more than 10 years ings suggest that BTB autografts may be optimal for ACL
old may have outdated rehabilitation protocols that could reconstruction in high-demand athletes to improve overall
affect RTS rates. Also, given that most of these data were RTS rates. However, among those athletes who did return
acquired via patient-reported outcomes, the shortcomings to sport, the rate of return to preinjury activity levels was
very similar between both graft options. What is interesting
in standardization were problematic for the acquisition of
is that regardless of the graft type, less than half of the
unbiased and uniform data. Additional studies would ben-
athletes ever returned to sport at the preinjury level after
efit greatly from the use of standardized self-assessment
primary ACL reconstruction. Additional high-quality ran-
scoring systems designed for reporting RTS data in
domized trials are warranted in this field, with increased
patient-athletes.
attention paid to stratification by competition level, sport
As with any systematic review assessing RTS, there was
played, and return performance as well as enhanced efforts
a lack of consistency in the definitions of subjective out-
toward clarity in defining RTS and return to preinjury
comes, particularly RTS and return to preinjury levels
activity levels to definitively establish the equivalence or
among patient-athletes. In a previous study by our group,
nonequivalence of these 2 autograft types in athletes.
we noted that the reporting of RTS and return to preinjury
level suffers from the lack of a clear consensus definition as
to what these terms specifically mean to athletes.1 RTS
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APPENDIX

TABLE A1
Sports Played, Level of Athletics, Concomitant Procedures, and Revision Surgery for Studies With BTB Autograftsa

First Author (Year)

Gobbi16 (2002)
Sports played Downhill skiing (n ¼ 8), motocross (n ¼ 6), basketball (n ¼ 6), soccer (n ¼ 6), tennis (n ¼ 4), volleyball (n ¼ 4),
mountain biking (n ¼ 3), handball (n ¼ 1), alpinism (n ¼ 1), horseback riding (n ¼ 1)
Level of athletics Competitive (n ¼ 35), recreational (n ¼ 5)
Concomitant procedures None
Revision surgery Cyclops lesion excision (n ¼ 2), lateral patellar chondropathy (n ¼ 1), medial meniscectomy (n ¼ 1), tibial bone
block repositioning with interference screw (n ¼ 1)
Shaieb47 (2002)b
Sports played Soccer (n ¼ 3), skiing (n ¼ 6), basketball (n ¼ 4), baseball (n ¼ 2), football (n ¼ 3), volleyball (n ¼ 3), softball (n ¼ 1),
martial arts (n ¼ 2), work (n ¼ 4), other (n ¼ 3)
Level of athletics Mixed
Concomitant procedures Medial meniscectomy (n ¼ 8), lateral meniscectomy (n ¼ 7), bilateral meniscectomy (n ¼ 2)
Revision surgery Manipulation under anesthesia (n ¼ 1), tibial interference screw removal for infection (n ¼ 1), revision ACL
reconstruction (n ¼ 1)
Feller14 (2003)b
Sports played Most commonly Australian rules football and basketball; work (n ¼ 2)
Level of athletics NR
Concomitant procedures Partial medial meniscectomy (n ¼ 6), medial meniscal repair (n ¼ 5), partial lateral meniscectomy (n ¼ 6), lateral
meniscal repair (n ¼ 1)
Revision surgery Revision ACL reconstruction (n ¼ 1), debridement for infection (n ¼ 1), debridement for notch impingement
(n ¼ 2), partial medial meniscectomy (n ¼ 1), diagnostic arthroscopic surgery (n ¼ 2)
Jennings25 (2003)
Sports played NR
Level of athletics NR
Concomitant procedures Medial meniscal excision (n ¼ 15), lateral meniscal excision (n ¼ 2)
Revision surgery Medial meniscal excision (n ¼ 1), tibial staple removal (n ¼ 5), cyclops lesion excision (n ¼ 1)
(continued)
The Orthopaedic Journal of Sports Medicine Return to Sport: BTB Versus Hamstring Tendon Graft 13

Table A1 (continued)

First Author (Year)

Mascarenhas35 (2012)b
Sports played Basketball (n ¼ 10), football (n ¼ 3), soccer (n ¼ 3), skiing (n ¼ 2), dancing/gymnastics (n ¼ 3), martial arts (n ¼ 1),
wrestling (n ¼ 1)
Level of athletics Mixed
Concomitant procedures Meniscal repair (n ¼ 3), meniscectomy (n ¼ 5)
Revision surgery Arthroscopic knee debridement (n ¼ 1)
Daruwalla10 (2014)b
Sports played Football
Level of athletics NCAA Division I
Concomitant procedures NR
Revision surgery NR
Kautzner26 (2015)b
Sports played NR
Level of athletics Professional (n ¼ 4), amateur (n ¼ 35)
Concomitant procedures NR
Revision surgery Cyclops lesion excision for revision (n ¼ 1), diagnostic arthroscopic surgery for persistent instability (n ¼ 3)
Sandon43 (2015)b
Sports played Soccer
Level of athletics NR
Concomitant procedures NR
Revision surgery NR
Sonnery-Cottet48 (2017)b
Sports played NR
Level of athletics NR
Concomitant procedures Medial meniscectomy (n ¼ 5), medial suture (n ¼ 46), lateral meniscectomy (n ¼ 6), lateral suture (n ¼ 24)
Revision surgery Meniscectomy (n ¼ 4), cyclops lesion excision (n ¼ 5)
Liptak33 (2017)b
Sports played Australian rules football
Level of athletics Elite
Concomitant procedures NR
Revision surgery NR
Gupta19 (2018)b
Sports played Mixed
Level of athletics NR
Concomitant procedures NR
Revision surgery NR
a
ACL, anterior cruciate ligament; BTB, bone–patellar tendon–bone; NCAA, National Collegiate Athletic Association; NR, not reported.
b
Study compared BTB and hamstring tendon (HT) grafts.
14 DeFazio et al The Orthopaedic Journal of Sports Medicine

TABLE A2
Sports Played, Level of Athletics, Concomitant Procedures, and Revision Surgery for Studies With HT Autograftsa

First Author (Year)

Shaieb47 (2002)b
Sports played Soccer (n ¼ 2), skiing (n ¼ 3), basketball (n ¼ 11), baseball (n ¼ 2), football (n ¼ 3), volleyball (n ¼ 5), softball
(n ¼ 2), work (n ¼ 2), motor vehicle (n ¼ 3), other (n ¼ 2)
Level of athletics Mixed
Concomitant procedures Medial meniscectomy (n ¼ 7), lateral meniscectomy (n ¼ 5), medial and lateral meniscectomy (n ¼ 2), lateral
meniscal repair (n ¼ 4)
Revision surgery Revision ACL reconstruction (n ¼ 2)
Gobbi17 (2003)
Sports played Soccer (n ¼ 18), downhill skiing (n ¼ 21), motocross (n ¼ 11), basketball (n ¼ 9), volleyball (n ¼ 9), tennis (n ¼ 4),
mountain biking (n ¼ 2), handball (n ¼ 2), alpinism (n ¼ 2), horseback riding (n ¼ 2)
Level of athletics Mixed
Concomitant procedures NR
Revision surgery Diagnostic arthroscopic surgery for partial graft rupture (n ¼ 1), partial medial meniscectomy (n ¼ 1), removal of
Fastlok device (n ¼ 7), arthroscopic lavage and debridement for deep infection (n ¼ 1)
Feller14 (2003)b
Sports played Most commonly Australian rules football and basketball
Level of athletics NR
Concomitant procedures Partial medial meniscectomy (n ¼ 4), medial meniscal repair (n ¼ 4), partial lateral meniscectomy (n ¼ 6)
Revision surgery Removal of prominent fixation post (n ¼ 1), medial meniscectomy (n ¼ 1), manipulation under anesthesia for lack
of extension (n ¼ 1)
Lee31 (2008)
Sports played NR
Level of athletics National (n ¼ 2), recreational (n ¼ 43), competitive (n ¼ 21)
Concomitant procedures NR
Revision surgery NR
Ardern3 (2012)
Sports played Australian football (n ¼ 82), netball (n ¼ 67), basketball (n ¼ 44), soccer (n ¼ 38), other (n ¼ 83)
Level of athletics Competitive sport before injury (n ¼ 198), recreational (n ¼ 56), social competitions (n ¼ 38), training (n ¼ 22)
Concomitant procedures NR
Revision surgery NR
Mascarenhas35 (2012)b
Sports played Basketball (n ¼ 10), football (n ¼ 4), soccer (n ¼ 4), skiing (n ¼ 2), dancing/gymnastics (n ¼ 1), softball (n ¼ 1),
lacrosse (n ¼ 1)
Level of athletics Mixed
Concomitant procedures Meniscectomy (n ¼ 3), meniscal repair (n ¼ 5)
Revision surgery Knee arthroscopic surgery (n ¼ 1)
Daruwalla10 (2014)b
Sports played Football
Level of athletics NCAA Division I
Concomitant procedures NR
Revision surgery NR
Kyung29 (2015)
Sports played Mostly soccer
Level of athletics NR
Concomitant procedures Meniscectomy (n ¼ 28), meniscal repair (n ¼ 20)
Revision surgery Debridement for deep knee joint infection (n ¼ 1) and superficial tibial infection (n ¼ 3)
Sandon43 (2015)b
Sports played Soccer
Level of athletics NR
Concomitant procedures NR
Revision surgery NR
Kautzner26 (2015)b
Sports played NR
Level of athletics Professional (n ¼ 6), amateur (n ¼ 36)
Concomitant procedures NR
Revision surgery NR
Rodriguez-Roiz40 (2015)
Sports played Football (n ¼ 53), basketball/handball/volleyball (n ¼ 12), tennis/paddle tennis (n ¼ 5), skiing/snowboarding
(n ¼ 8), gymnasium activities/cycling (n ¼ 21)
(continued)
The Orthopaedic Journal of Sports Medicine Return to Sport: BTB Versus Hamstring Tendon Graft 15

Table A2 (continued)

First Author (Year)

Level of athletics Recreational

Concomitant procedures Meniscectomy (n ¼ 32), meniscal repair (n ¼ 20), microfracture (n ¼ 6)
Revision surgery NR
Liu34 (2016)
Sports played Basketball (n ¼ 16), running (n ¼ 14), soccer (n ¼ 12), badminton/table tennis (n ¼ 9)
Level of athletics NR
Concomitant procedures Lateral meniscectomy (n ¼ 13), lateral meniscal repair (n ¼ 12), medial meniscectomy (n ¼ 19), medial meniscal
repair (n ¼ 4)
Revision surgery NR
Notarnicola38 (2016)
Sports played Jogging (n ¼ 2), cycling (n ¼ 2), volleyball (n ¼ 3), tennis (n ¼ 3), basketball (n ¼ 2), soccer (n ¼ 54), running
(n ¼ 4), athletics (n ¼ 10)
Level of athletics Amateur
Concomitant procedures None
Revision surgery NR
Sonnery-Cottet48 (2017)b
Sports played NR
Level of athletics Professional (n ¼ 6), mixed
Concomitant procedures Medial meniscectomy (n ¼ 5), medial meniscal repair (n ¼ 48), lateral meniscectomy (n ¼ 7), lateral meniscal repair
(n ¼ 35)
Revision surgery Meniscectomy (n ¼ 7)
Webster52 (2017)
Sports played Australian rules football, netball, soccer, basketball
Level of athletics NR
Concomitant procedures NR
Revision surgery NR
Liptak33 (2017)b
Sports played Australian rules football
Level of athletics Elite
Concomitant procedures NR
Revision surgery NR
Gupta19 (2018)b
Sports played Mixed
Level of athletics NR
Concomitant procedures NR
Revision surgery NR
Edwards11 (2018)
Sports played Australian football (n ¼ 25), soccer (n ¼ 20), netball (n ¼ 17), basketball (n ¼ 15), other (n ¼ 36)
Level of athletics Level I/II sports
Concomitant procedures Meniscectomy (n ¼ 47), meniscal repair (n ¼ 4)
Revision surgery NR
a
ACL, anterior cruciate ligament; HT, hamstring tendon; NCAA, National Collegiate Athletic Association; NR, not reported.
b
Study compared bone–patellar tendon–bone (BTB) and HT grafts.