Hamstring Tendon vs. Bone-Patellar Tendon-Bone Grafts for Primary Anterior Cruciate Ligament Reconstruction in Football (Soccer) Players: A Systematic Review and Meta-Analysis.

Abstract

Anterior cruciate ligament (ACL) rupture is a common and career-impacting injury among football players, often requiring surgical reconstruction. The two most commonly used grafts, hamstring tendon (HT) and bone-patellar tendon-bone (BPTB), have both shown favorable outcomes, but the optimal choice remains debated. This systematic review aimed to evaluate and compare outcomes of ACL reconstruction using HT vs. BPTB autografts specifically in football players. A systematic literature search was conducted across PubMed, Cochrane Library, and MEDLINE databases from inception to January 2025. Eligible studies included randomized controlled trials and observational cohort or case-control studies comparing HT and BPTB autografts in football players undergoing primary ACL reconstruction. The primary outcome was graft failure rate. Secondary outcomes included return to sport, isokinetic muscle strength, patient-reported outcome measures (PROMs), donor-site morbidity, and knee stability. Meta-analyses were performed for outcomes reported in ≥2 studies with statistical heterogeneity (I²) ≤ 60%. Outcomes with high heterogeneity or limited reporting were summarized narratively using the Synthesis Without Meta-analysis (SWiM) guidelines. Risk of bias was assessed using the Risk of Bias 2 (RoB2) and Risk of Bias in Non-Randomized Studies of Interventions Version 2 (ROBINS-I V2) tools. Nine studies with 1,173 participants met the inclusion criteria. Meta-analysis of five studies (n = 1,013) showed no statistically significant difference in graft failure rates between the graft types (HT: 7.88%, BPTB: 6.34%, OR = 1.46, 95% CI: 0.80-2.67, <i>p</i> = 0.22). Return-to-sport rates were also comparable between graft types. Evidence for secondary outcomes was limited. Meta-analysis of extensor strength, based on two studies and heavily weighted toward a single trial, suggested greater strength following HT reconstruction, while flexor strength and donor-site morbidity findings were derived from single studies. PROMs and knee stability outcomes showed no consistent differences. Risk of bias was moderate to serious in most observational studies. This systematic review and meta-analysis found no clear superiority between HT and BPTB grafts in terms of failure rates, return to sport, or stability outcomes in football players. In contrast, evidence regarding muscle strength recovery and donor-site morbidity remains limited and preliminary. These secondary findings should be interpreted cautiously, highlighting the need for further high-quality, football-specific trials.