BPTB autografts are widely considered the gold standard for ACL reconstruction. The aims of this study were to compare the clinical outcomes following ACLR with « gold standard » BPTB versus combined ACLR+anterolateral ligament reconstruction at medium term follow-up in a large series of propensity matched patients.

Patients undergoing combined ACL and ALLR using HT between January 2003 and December 2019 were propensity matched in a 1:1 ratio to patients undergoing isolated ACLR using BPTB. At the end of the study period graft rupture, contralateral knee injury and any other reoperations or complications after the index procedure were identified by interrogation of a prospective database and review of medical records.

A total of 1009 matched pairs were included. The mean duration of follow-up was 101.3±59.9 months. Patients in the BPTB group were>3-fold more likely to have a graft failure than those in the combined group (Hazard Ratio (HR)=3.554 [1.744;7.243] (p=0.0005). Patients aged less than 20 years were at particularly high risk of graft rupture (HR)=5.65 [1.834;17.241] (p=0.0002). Subgroup analysis demonstrated that isolated ACLR with BPTB conferred a>3 fold increased risk of graft rupture in young patients when compared to ACLR+ALLR with HT. Additionally, there was a significantly higher reoperation rate following isolated ACLR (BPTB group 20.5%, combined group 8.9%, p<0.0001). The overall rate of subsequent contralateral rupture was 9.1% for both groups after the index surgery (BPTB 10.2% vs. ACL+ALLR 8.0%, p=0.09) indicating that overall risk profiles for both groups were similar.

Patients who underwent isolated ACLR with BTB autografts experienced significantly worse ACL graft survivorship and overall re-operation free survivorship when compared to those who underwent combined ACLR+ALLR with hamstring autografts. The risk of graft rupture was more than 3-fold higher in patients who underwent isolated ACLR using BPTB.