In primary anterior cruciate ligament (ACL) reconstruction, a bone-patellar tendon-bone (BTB) autograft is associated with lower ipsilateral failure rates. BTB grafts are associated with a higher rate of contralateral ACL injury, which some clinicians view as a marker of success of the BTB graft. However, there is a lack of evidence on whether BTB grafts improve the rate of return to activity and sport.
To compare the rate of return to pre-injury activity levels between the BTB autograft and the hamstring tendon autograft in high activity patients.
Study Design: Cohort Study.
This study followed a high-activity (pre-injury Marx score >12) cohort of 1,844 patients who underwent primary ACL reconstruction between 2014 and 2018. Prospectively collected data from the New Zealand ACL Registry, including pre-injury and post-operative Marx activity scores, were analyzed. The proportion of patients who returned to their pre-injury activity level at 1- and 2-year follow-up were compared between graft types.
Overall, 11.3% (208 out of 1,844) of patients returned to their pre-injury activity level at 1-year follow-up, while 15.5% (184 out of 1,190) returned at 2-year follow-up. At 1-year follow-up, 17.2% of patients with a BTB autograft returned to their pre-injury activity level compared to 9.3% of patients with a hamstring tendon autograft (adjusted OR = 1.59, 95% CI 1.17 – 2.17, p = 0.003). At 2-year follow-up, 23.3% of BTB patients returned to their pre-injury level compared to 13.3% of hamstring tendon patients (adjusted OR = 1.63, 95% CI 1.14 – 2.34, p = 0.008). Male sex and younger age were associated with a higher return to activity at both follow-up timepoints.
The use of a BTB autograft increased the odds of a return to pre-injury activity level at early follow-up. A higher return to activity is a possible explanation for the higher rate of contralateral ACL injury with BTB autograft use.