Hamstring tendons or bone-patellar tendon-bone graft for anterior cruciate ligament reconstruction?

In anterior cruciate ligament (ACL) reconstruction, success depends on several factors: patient selection; surgical technique, taking account of associated meniscal and ligamentous lesions; and postoperative rehabilitation. Improved hamstring-tendon graft preparation and fixation techniques now provide results in terms of laxity and retear comparable to patellar tendon graft, which has long been the gold-standard for patients with strong functional demand, despite its higher risk of extension stiffness and anterior pain. Apart from a few exceptional preferential indications, such as hamstring tendon in growing children and patients whose lifestyle or occupation involves frequent kneeling and patellar tendon in case of severe medial laxity associated with ACL tear, either graft may be used for ACL reconstruction. The keypoints in the procedure are good tunnel positioning and hence good mastery of the surgical technique, and treatment of all associated lesions, and especially of occult meniscal lesions and rotational laxity due to anterolateral ligament deficiency, which requires associated extra-articular plasty. Graft choice is secondary and not a key to success.