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

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. 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. 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. 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. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.