A 22-year-old football player sustains a non-contact deceleration injury with a 'pop' and immediate swelling. Lachman test is positive. ACL reconstruction is planned. Regarding graft choice, a bone-patellar tendon-bone (BTB) graft is preferred for which patient profile compared to a hamstring tendon graft?

• A Revision ACL reconstruction and elite pivoting sport athletes requiring highest graft stiffness and bone-to-bone healing ✓
• B Female athletes, due to higher quadriceps strength and lower donor site morbidity
• C Patients with concurrent medial collateral ligament tears, due to synergistic anatomical positioning
• D Older recreational athletes, due to superior vascularisation in degenerative knees

Explanation

BTB grafts offer bone-to-bone healing at the fixation sites (tunnels), which is faster and stronger than soft tissue healing seen with hamstring tendon grafts. BTB grafts also have higher initial stiffness and ultimate tensile load. For this reason, BTB is preferred in revision ACL surgery (where tunnel anatomy may be compromised), in elite athletes in high-demand pivoting sports, and when the highest mechanical properties are required early. Donor site morbidity (anterior knee pain, kneeling discomfort) is a disadvantage. Hamstring grafts (4-strand semitendinosus-gracilis) are preferred in patients with patellofemoral syndrome, open physes (paediatric), or when preserving patellar tendon integrity is important.

Reference: Maheshwari Essential Orthopaedics, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.