Hamstring Tendon Versus Bone-Patellar Tendon-Bone Autograft for ACL Reconstruction with Concurrent Lateral Extra-Articular Procedure

Background: No studies have yet evaluated the clinical outcomes of different anterior cruciate ligament (ACL) autografts in combination with a lateral extra-articular procedure (LEP). Thus, we systematically reviewed randomized controlled trials (RCTs) and conducted a network meta-analysis (NMA) to compare graft options for ACL reconstruction (ACLR) with concurrent LEP. Methods: A systematic search in the PubMed, Embase, Cochrane Library, and Google Scholar databases identified RCTs on primary ACLR plus LEP. Data on ACLR failure, residual knee instability, patient-reported outcome measures, and complications were analyzed using NMA. Results: On the basis of 13 studies (1,690 patients), ACLR with a hamstring tendon (HT) autograft plus LEP was associated with significantly lower odds of graft rupture (odds ratio [OR]: 0.28; 95% confidence interval [CI]: 0.16 to 0.50), graft failure (OR: 0.27; 95% CI: 0.15 to 0.47), clinical failure (OR: 0.48; 95% CI: 0.36 to 0.65), and residual pivot shift (OR: 0.43; 95% CI: 0.22 to 0.84) compared with isolated ACLR. Bone-patellar tendon-bone (BPTB) autograft plus LEP was associated with a significantly lower clinical failure rate (OR: 0.30; 95% CI: 0.12 to 0.80) compared with isolated ACLR. Both HT (mean difference [MD]: 2.40; 95% CI: 1.25 to 3.55) and BPTB (MD: 3.70; 95% CI: 0.85 to 6.55) autograft plus LEP were associated with higher Lysholm scores compared with isolated ACLR. The outcomes did not differ between the graft types when combined with LEP. Conclusions: The odds of graft rupture, graft failure, and clinical failure after ACLR with HT autograft plus LEP were lower by 72%, 73%, and 52%, respectively, than the odds after isolated ACLR. ACLR with BPTB autograft plus LEP significantly lowered only the odds of clinical failure, by approximately 70%, potentially due to the smaller sample size. Both grafts remain viable options for ACLR plus LEP, with the benefit of LEP requiring further validation. Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.