I recently saw a 48-year-old in my office who tore his ACL skiing. He is very active, participating in both winter and racket sports, and wants to return to that level. He had already seen a colleague who told him that he had to undergo a patellar tendon autograft ACL reconstruction because this is the “gold standard.” He came to see me for a second opinion, wanting to discuss whether there were any other options, since none had been offered to him.
This is not a unique example. In fact, it happens often enough that I felt it was worth writing about.
First off, there is no such thing as a “gold standard” in ACL reconstruction. Like most things in medicine, the choice of graft depends on who you are and what you want to do. Some surgeons, however, seem to forget this, and in their eyes the choice becomes more about what they are comfortable with than what is best for the patient.
There is a recent publication (link here) in the American Journal of Sports Medicine from the Swedish Knee Ligament Registry that speaks directly to this issue. What is particularly valuable about these registry studies, especially those from Scandinavia, is that every single surgery is entered and followed. This removes many of the biases related to individual surgeon skill, preference, and belief, and provides a more honest picture of outcomes across an entire population—young and old, active and sedentary.
This particular study reported on failure rates in over 44,000 patients who underwent ACL reconstruction using either quadriceps tendon, patellar tendon, or hamstring tendon autografts. A subset of approximately 19,000 of these patients also had patient-reported outcome scores available. These scores reflect how patients perceive their activity level, pain, and overall function in daily life and sports.
What was fascinating about this study was that patients who underwent quadriceps or hamstring tendon grafts were more likely to achieve an outcome that they considered satisfactory compared to those who had a patellar tendon graft—the so-called “gold standard.” At the same time, there were no meaningful differences in failure rates between the three graft types, all of which were below 3%.
If there is little to no difference in failure rates, then the logical next step is to choose the graft that causes the least long-term problems.
A study from Hospital for Special Surgery (link here) that analyzed 21 randomized controlled trials with more than 1700 patients comparing the same graft types found a 69% lower chance of donor-site morbidity—meaning problems related to where the graft is taken from—with hamstring or quadriceps grafts compared to patellar tendon autografts.
Another study (link here) showed that persistent and severe kneeling pain was three times more likely with patellar tendon grafts than with hamstring grafts.
Yet another analysis of 12 randomized controlled trials (link here) involving more than 1,400 patients demonstrated that while there were no differences in stability or graft failure, there were significant differences in anterior knee pain, kneeling pain, and the development of osteoarthritis, all of which were higher in patients who had patellar tendon grafts.
So while there may be differences in certain subgroups, particularly in very young patients, for my 48-year-old patient there are no meaningful differences in failure rates between graft types. Given that, I recommended choosing the option with the lowest risk of long-term problems, which in his case was a hamstring autograft.
And as for those very young patients, even there the story is not so simple. A study comparing patellar tendon reconstruction to the technique I prefer for these patients - hamstring autograft combined with a lateral extra-articular tenodesis - showed that the patellar tendon group had a fourfold higher failure rate.
I try to find the right balance between risk and reward for each individual patient, and that balance depends on who you are and what you want to return to. For that reason, I do not think I have ever used the term “gold standard.”