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Why bone–patella tendon–bone grafts should still be considered the gold standard for anterior cruciate ligament reconstruction
  1. James R Carmichael,
  2. Mervyn J Cross
  1. North Sydney Orthopaedic and Sports Medicine Centre, 286 Pacific Highway, Crows Nest, NSW 2065, Australia
  1. James R Carmichael, BMedSci, BMBS, MSc, FRCS (Tr. & Orth.), Orthopaedic Fellow, North Sydney Orthopaedic and Sports Medicine Centre, 286 Pacific Highway, Crows Nest, NSW 2065, Australia; orthojim{at}

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The patient population that will place the highest demand on the structural integrity and function of an ACL graft, whilst at the same time having the lowest tolerance for any donor site morbidity, is the professional sportsman or woman. The graft most appropriate for this group, regardless of technical difficulties, should therefore be considered the gold standard. We believe that the bone – patella tendon – bone (BPTB) graft best fits these criteria.

Proponents of the hamstring-based reconstruction will often cite the morbidity of the patellar tendon harvest, rather than the merits of the hamstrings, as the principal reason for avoiding the use of BPTB. Concerns exist regarding quadriceps deficit, arthritis, postoperative stiffness, anterior knee pain and sensory disturbance. The complications associated with hamstrings grafts must not be forgotten. These include increased knee laxity, hamstrings deficit and pain, tunnel widening, anterior knee pain and sensory deficit.


Graft laxity and fixation

The stability of the hamstrings reconstruction when compared with the BPTB graft is frequently questioned. It is a common finding that there is a trend to increased laxity when hamstrings grafts are used.13 This has been confirmed in a meta-analysis by Goldblatt et al, who identified a marked reduction in side-to-side laxity difference with the use of the BPTB graft.4 A similar analysis by Forster et al identified a trend to increased chance of a positive pivot jerk in the hamstrings group.5 When laxity is identified in a BPTB graft it is usually associated with tunnel misplacement.6

The cause for the increased laxity with hamstrings has been studied. In 2002 Rittmeister et al analysed the components of postoperative laxity in a cadaveric study.7 They found that the majority of graft slippage occurred at the graft bone interface, with only 8% of elongation being due to plastic …

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  • Competing interests: None.

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