Comparison of Patellar Tendon and Hamstring Grafts in ACL Reconstruction: Patellar Tendon Shows Lower Re-Rupture Rates in High-Risk Groups but Comparable Outcomes in Low-Risk Patients

Comparison of Patellar Tendon and Hamstring Grafts in ACL Reconstruction: Patellar Tendon Shows Lower Re-Rupture Rates in High-Risk Groups but Comparable Outcomes in Low-Risk Patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of Patellar Tendon and Hamstring Grafts in ACL Reconstruction: Patellar Tendon Shows Lower Re-Rupture Rates in High-Risk Groups but Comparable Outcomes in Low-Risk Patients Kazumi Goto, Eisaburo Honda, Hiroshi Iwaso, Shin Sameshima, Miyu Inagawa, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7099142/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Feb, 2026 Read the published version in Archives of Orthopaedic and Trauma Surgery → Version 1 posted 7 You are reading this latest preprint version Abstract Purpose To compare re-rupture rates and clinical outcomes between bone–patellar tendon–bone (BTB) and hamstring tendon (HT) grafts in anterior cruciate ligament (ACL) reconstruction according to patient risk levels. Methods This retrospective cohort study included patients who underwent primary ACL reconstruction at a single institution between 2018 and 2022, with a minimum of two years of follow-up. High-risk patients were defined as those aged ≤ 20 years, with posterior tibial slope ≥ 12°, and participating in pivoting sports. In this group, re-rupture rates and Knee injury and Osteoarthritis Outcome Score (KOOS) were compared between the BTB and HT grafts. For patients with two or fewer risk factors, propensity score matching was performed to compare outcomes. Results In the high-risk group, the BTB graft showed a significantly lower re-rupture rate compared to the HT graft (12.9% vs. 35.7%, p = 0.03), with no significant difference in KOOS (96.3 ± 3.7 vs. 96.6 ± 6.3, p = 0.85). In the lower-risk group after matching, the BTB graft showed a similar re-rupture rate compared to the HT graft (8.2% vs. 6.8%, p = 0.99), with no significant difference in KOOS (94.5 ± 5.0 vs. 94.9 ± 6.6, p = 0.73). Conclusion BTB grafts reduced re-rupture rates compared to HT grafts in high-risk ACL reconstruction patients, while clinical outcomes were similar. In lower-risk patients, no significant differences were observed between graft types in either re-rupture rates or KOOS. Level of Evidence Level III anterior cruciate ligament reconstruction risk factor posterior tibial slope bone patellar-tendon bone hamstring autograft Figures Figure 1 Figure 2 Introduction Recent high-quality meta-analyses and national registry-based big data studies have established a consensus that bone patellar-tendon bone (BTB) autografts result in lower re-rupture rates compared to hamstring tendon (HT) autografts in primary anterior cruciate ligament (ACL) reconstruction [ 1 , 2 ]. Although some studies report no statistically significant difference in re-rupture rates between BTB and HT grafts, most show consistently lower re-rupture rates with BTB [ 3 – 5 ]. This may be attributed to the stronger and faster graft incorporation of BTB compared to HT, as well as the intrinsic biomechanical properties of the graft itself [ 6 ]. Recently, BTB grafts have been increasingly favored over HT grafts in high-risk patients, such as those with generalized joint laxity or younger age [ 7 ]. This preference may be supported by evidence that patients with generalized joint laxity had a fourfold higher revision risk when HT grafts were used, compared to BTB grafts [ 8 ]. Despite growing attention to individualized graft selection based on risk assessment, no studies have directly compared re-rupture rates and clinical outcomes between these graft types according to patient risk profiles. The primary objective of this study was to compare re-rupture rates and clinical outcomes between BTB and HT autografts across different risk levels, in order to clarify differences in outcomes based on patient risk profiles. As a secondary objective, re-rupture rates and outcomes were compared between the two groups after adjusting for confounding factors, allowing for a comparison between patients with similar baseline characteristics. It was hypothesized that BTB grafts would result in lower re-rupture rates in high-risk patients, whereas no significant differences in re-rupture rates or clinical outcomes would be observed between the two graft types after adjustment for risk factors. Materials and Methods Patient selection This retrospective cohort study was approved by the institutional review board. Patients who underwent primary ACL reconstruction using either HT or BTB autografts between 2018 and 2022 were reviewed. Inclusion criteria were a minimum follow-up of two years. The exclusion criteria were as follows: previous ipsilateral knee injuries, osteoarthritis greater than Kellgren-Lawrence grade 3, contralateral ACL injuries during follow-up, and grade 3 concomitant collateral ligament injuries. Surgical Indications and Technique ACL reconstruction was performed in patients diagnosed with primary ACL injury who either wished to return to sports or experienced instability that interfered with activities of daily living. The choice of graft type (HT or BTB) was determined by multiple operating surgeons based on individual preferences and patient-specific factors. For ACL reconstruction using HT, a double-bundle technique was employed. Femoral tunnels were primarily created using the modified transtibial technique [ 9 ], while the transportal or outside-in technique was also applied depending on the case. For ACL reconstruction using BTB grafts, femoral tunnels were created using the transportal technique with a rectangular method [ 10 ]. Graft fixation involved a suspensory device on the femoral side, while either a button or a post screw was used on the tibial side, depending on the surgeon’s preference. Using a tensioning device (Arthrex, Naples, FL, USA), the graft was fixed in a fully extended knee position with a tension ranging from 60 to 80 N. The tension was set to the level deemed optimal for the patient and confirmed intraoperatively with the pivot-shift test [ 11 ]. A standardized post-operative rehabilitation protocol was applied to all patients [ 11 ]. Outcome Measurements and MCID The following demographic and clinical parameters were extracted from medical records: age, sex, height, weight, laterality, time from injury to surgery, pre-operative sports type, pre-operative Tegner Activity Scale, presence of meniscal injury, knee hyperextension of 10°, generalized joint laxity (GJL), and posterior tibial slope angle (PTS). GJL was evaluated using an 8-level scoring system (0–7) based on The University of Tokyo joint laxity test [ 12 ]. PTS was measured on medial tibial slopes using radiographs, following the method described in previous research [ 11 ]. Pre-operative sports type was categorized as pivoting or non-pivoting according to prior studies [ 13 ]. The primary outcome was defined as the presence or absence of re-rupture at two years postoperatively. Secondary outcomes included the evaluation of anteroposterior laxity using arthrometry, the Knee Injury and Osteoarthritis Outcome Score (KOOS) [ 14 , 15 ], and the Anterior Cruciate Ligament-Return to Sport Injury (ACL-RSI) scale [ 16 ]. Anteroposterior laxity was measured using the digital arthrometer device (Kneelax3; Monitored Rehab Systems, Haarlem, The Netherlands) by determining the difference between the surgical and healthy sides at 132 N with the knee flexed at 30° [ 11 ]. To assess clinical relevance, the minimal clinically important difference (MCID) for total KOOS score was calculated using a distribution-based method: one-half of the standard deviation (1/2 SD) of the change scores (Δ). The proportion of patients exceeding these thresholds was calculated for each group. Risk Factors Based on our previous research, age ≤ 20 years, PTS ≥ 12 degrees, and preoperative participation in pivoting sports were hypothesized as risk factors [ 13 ]. To validate the accuracy of this risk definition, logistic regression analysis was performed by including four additional factors: Graft type (BTB or HT), GJL, sex, and hyperextension of the knee, along with the original three risk factors. These additional variables were selected based on previous literature [ 17 ] reporting them as potential but controversial risk factors for graft re-rupture, with the aim of examining their significance within our cohort. As a result, the only significant independent risk factors were age ≤ 20 years, PTS ≥ 12 degrees, and preoperative participation in pivoting sports, consistent with previous findings [ 13 ]. Therefore, these three factors were adopted as the risk criteria (Table 1 ). Table 1 Results of the logistic regression analysis Variable Odds Ratio 95% CI Lower 95% CI Upper P-value (Intercept) < 0.01 0 Inf 0.99 Sex (male) 1.01 0.44 2.30 0.98 HT graft 1.29 0.51 5.79 0.59 GJL 1.05 0.82 1.35 0.68 Hyperextension < 0.01 0 Inf 0.99 Pivoting sports 3.47 1.16 10.4 0.03 PTS ≥ 12° 2.62 1.23 5.57 0.01 Age ≤ 20 years 2.59 1.16 5.79 0.02 CI: confidence intervals; HT, hamstring tendon; GJL, generalized joint laxity; PTS, posterior tibial slope Patients with all three risk factors were defined as the high-risk group, and outcomes were compared between BTB and HT grafts within this group (Fig. 1). Additionally, for cases with two or fewer risk factors, propensity scores were calculated using five variables—age ≤ 20 years, PTS ≥ 12 degrees, preoperative participation in pivoting sports, surgical timing after injury, and preoperative Tegner Activity Scale—which had shown significant between-group differences in baseline characteristics, and 1:1 matching was performed. Outcomes were then compared between the BTB and HT graft groups (Fig. 2 ). Figure 1. Flowchart illustrating the criteria for inclusion in and exclusion from the study ACL, anterior cruciate ligament; BTB, bone patellar-tendon bone; HT, hamstring tendon; KL, Kellgren-Lawrence grading; PTS, posterior tibial slope Flowchart of propensity score matching ACLR, anterior cruciate ligament reconstruction; BTB, bone patellar-tendon bone; HT, hamstring tendon; KL, Kellgren-Lawrence grading; PTS, posterior tibial slope Statistical Analyses All statistical analyses were performed using R software (version 4.2.1; R Development Core Team, Vienna, Austria). Mean values and standard deviations were used for continuous variables that showed a normal distribution, whereas medians and interquartile ranges were used for continuous variables that did not show a normal distribution. We used Student’s t-tests, Mann–Whitney U tests, and chi-square tests to compare means, medians, and nominal variables, respectively, when comparing clinical outcomes, demographic variables, pre-operative variables, and intraoperative variables between the groups. To evaluate clinically meaningful improvement, the MCID for total KOOS score was calculated using a distribution-based method. Specifically, the MCID threshold was defined as one-half of the standard deviation (1/2 SD) of the change score (Δ = postoperative – preoperative). The proportion of patients who met or exceeded this threshold was determined for each group and used for between-group comparisons. A post hoc power analysis was performed to assess whether the sample size was sufficient to detect differences in the primary outcome (re-rupture rate) between the BTB and HT groups. Assuming an alpha level of 0.05 and the observed re-rupture rates in the high-risk group (12.9% for BTB and 35.7% for HT), the power to detect a statistically significant difference was 99.7%, indicating that the sample size in this subgroup was adequate. Results A total of 1,770 cases were screened. After applying exclusion criteria, 705 patients met the eligibility requirements and were included in the analysis (Fig. 1). The demographic data are summarized in Table 2 . Overall, re-ruptures were observed in 37 out of 586 cases (6.3%) in the HT group and 12 out of 119 cases (10.1%) in the BTB group. In the high-risk group, the re-rupture rate was 15 out of 42 cases (35.7%) in the HT group and 4 out of 31 cases (12.9%) in the BTB group, with a statistically significant difference (p = 0.03). The anteroposterior laxity difference between the surgical and healthy sides was 1.6 ± 2.2 mm in the hamstring tendon group and 0.7 ± 1.4 mm in the BTB group (p = 0.08). No statistically significant differences were observed in KOOS or ACL-RSI scores between the two groups at two years postoperatively (Table 3 ). The proportion of patients exceeding the MCID threshold for total KOOS score was also similar between the groups in the high-risk cohort (p = 0.60). Table 2 Patient demographics HT (n = 586) BTB (n = 119) p-value Age (years) 29.3 ± 13.0 20.6 ± 7.6 < 0.01 Sex (female/male) 324/262 61/58 0.08 Left/right 295/291 61/58 0.94 Height (cm) 165.4 ± 8.5 166.3 ± 9.4 0.29 Body weight (kg) 62.6 ± 11.8 67.2 ± 18.4 < 0.01 Surgical timing after injury (days) 75 (48–152) 52 (38–87) < 0.01 Generalized joint laxity 1 (0–7) 2 (0–7) < 0.01 Hyperextension knee 62 (11.8%) 20 (18.0%) 0.25 Tegner Activity Scale 6.6 ± 1.2 7.7 ± 1.5 < 0.01 Pivoting sports 346 (59.2%) 79 (66.4%) < 0.01 MM injury 190 (32.4%) 25 (21.0%) 0.02 LM injury 195 (33.3%) 36 (30.3%) 0.59 Posterior tibial slope angle (°) 10.1 ± 3.0 11.5 ± 3.0 < 0.01 Generalized joint laxity was scored using the University of Tokyo test (scores: 0–7) [ 12 ] HT, hamstring tendon: BTB, bone-patellar tendon-bone; MM, medial meniscus; LM, lateral meniscus Table 3 Comparison results in high-risk cases (patients with all three factors: age ≤ 20 years, PTS ≥ 12°, and participation in pivoting sports) HT (n = 42) BTB (n = 31) p-value Re-rupture, n (%) 15 (35.7%) 4 (12.9%) 0.03 Age (years) 15.7 ± 1.5 16.7 ± 1.6 < 0.01 Sex (female/male) 24/18 12/19 0.16 Left/right 20/22 16/15 0.82 Height (cm) 165.0 ± 9.2 167.9 ± 7.5 0.15 Body weight (kg) 57.2 ± 9.7 62.7 ± 11.0 0.03 Tegner Activity Scale 7.1 ± 0.6 7.8 ± 1.1 < 0.01 2-year KOOS Symptom 95.8 ± 6.0 93.0 ± 7.5 0.20 Pain 97.1 ± 5.4 97.5 ± 3.8 0.78 ADL 99.2 ± 3.1 99.6 ± 1.4 0.64 Sports 92.8 ± 16.7 94.0 ± 8.7 0.76 QOL 91.2 ± 16.9 88.8 ± 13.4 0.61 Overall 96.6 ± 6.3 96.3 ± 3.7 0.85 ∆KOOS (overall) 14.8 ± 11.1 13.3 ± 8.0 0.69 MCID (KOOS overall) 71.4% 77.4% 0.60 2-year ACL-RSI score 77.2 ± 21.1 68.7 ± 15.3 0.20 Data are expressed as means ± standard deviations, and n (%) HT, hamstring tendon: BTB, bone-patellar tendon-bone; 2-year KOOS, the 2-year postoperative Knee Injury and Osteoarthritis Outcome Score; MCID, minimal clinically important difference; ACL-RSI, Anterior Cruciate Ligament-Return to Sport Injury After propensity score matching, re-ruptures occurred in 5 out of 73 cases (6.8%) in the HT group and 6 out of 73 cases (8.2%) in the BTB group, with no statistically significant difference (Table 4 ). The anteroposterior laxity difference between the surgical and healthy sides was 1.0 ± 1.6 mm in the HT group and 0.9 ± 1.5 mm in the BTB group (p = 0.81). No significant differences were found in KOOS or ACL-RSI scores between the two groups at two years postoperatively (Table 4 ). Similarly, the proportion of patients exceeding the MCID threshold for total KOOS score did not differ significantly between the groups after matching (p = 0.99). Table 4 Demographic data before and after propensity score matching Pre-matching Post-matching HT (n = 544) BTB (n = 88) p-value HT (n = 73) BTB (n = 73) p-value Age (years) 30.3 ± 12.8 22.0 ± 8.3 < 0.01 23.3 ± 10.1 22.6 ± 8.8 0.63 Sex (female/male) 300/244 49/39 0.08 42/31 45/28 0.61 Left/right 275/269 45/43 0.96 39/34 39/34 0.99 Height (cm) 165.5 ± 8.4 165.8 ± 9.9 0.75 165.0 ± 7.9 164.9 ± 10.0 0.92 Body weight (kg) 62.9 ± 11.8 68.8 ± 20.1 < 0.01 63.0 ± 12.8 65.5 ± 16.7 0.31 Surgical timing after injury (days) 76 (48–152) 52 (38–87) < 0.01 67 (43–127) 54 (37–108) 0.15 Generalized joint laxity 1 (0–2) 2 (0–3) 0.06 1 (0–2) 2 (0–3) 0.12 Hyperextension knee 59 (12.1%) 15 (18.3%) 0.28 6 (8.8%) 14 (19.7%) 0.09 Tegner Activity Scale 6.5 ± 1.2 7.6 ± 1.7 < 0.01 7.4 ± 1.2 7.3 ± 1.6 0.91 Pivoting sports 304 (56.1%) 48 (54.5%) 0.82 40 (54.8%) 45 (61.6%) 0.50 MM injury 183 (33.6%) 18 (20.5%) 0.10 22 (30.1%) 15 (20.5%) 0.25 LM injury 184 (33.8%) 28 (31.8%) 0.81 25 (34.2%) 21 (28.8%) 0.59 Posterior tibial slope angle (°) 9.9 ± 3.0 10.7 ± 3.1 < 0.01 10.3 ± 2.5 10.3 ± 3.0 0.92 Re-rupture, n (%) 22 (4.0%) 8 (9.1%) 0.054 5 (6.8%) 6 (8.2%) 0.99 2-year KOOS Symptom 90.4 ± 9.6 90.4 ± 9.9 0.98 91.9 ± 8.0 90.6 ± 9.8 0.45 Pain 94.7 ± 7.4 94.2 ± 6.4 0.64 95.8 ± 6.3 94.3 ± 6.4 0.21 ADL 98.3 ± 5.9 99.1 ± 1.8 0.29 98.9 ± 2.3 99.2 ± 1.3 0.35 Sports 91.6 ± 12.9 89.5 ± 12.2 0.23 92.8 ± 11.4 90.5 ± 9.8 0.27 QOL 84.9 ± 16.6 85.9 ± 16.6 0.65 87.8 ± 12.6 86.7 ± 16.1 0.71 Overall 93.9 ± 7.3 94.2 ± 5.5 0.79 94.9 ± 6.6 94.5 ± 5.0 0.73 ∆KOOS (overall) 18.9 ± 13.2 13.6 ± 9.6 0.01 14.0 ± 8.2 17.9 ± 13.4 0.11 MCID (KOOS overall) 85.9% 82.2% 0.50 82.9% 80.9% 0.99 2-year ACL-RSI score 63.7 ± 22.6 67.2 ± 19.0 0.35 68.4 ± 21.3 67.0 ± 19.3 0.77 Data are expressed as means ± standard deviations, medians (interquartile ranges), and n (%) Generalized joint laxity was scored using the University of Tokyo test (scores: 0–7) [ 14 ] HT, hamstring tendon: BTB, bone-patellar tendon-bone; MM, medial meniscus; LM, lateral meniscus; 2-year KOOS, the 2-year postoperative Knee Injury and Osteoarthritis Outcome Score; MCID, minimal clinically important difference; ACL-RSI, Anterior Cruciate Ligament-Return to Sport Injury Discussion The most important finding in this study was that in patients with all three risk factors—age ≤ 20 years, PTS ≥ 12°, and participation in pivoting sports—the re-rupture rate at two years postoperatively was significantly lower in the BTB graft group compared to the HT graft group. However, after adjusting for confounding factors, no significant difference in re-rupture rates was observed between the two graft types. Additionally, in both the high-risk group and the propensity score-matched cohort, no significant differences were found in KOOS or ACL-RSI scores between the two groups at two years postoperatively. Based on these results, it may be advisable for surgeons concerned about re-rupture risk to consider BTB grafts over HT grafts in high-risk patients. Numerous studies have compared BTB and HT grafts, with a consensus that BTB grafts result in lower re-rupture rates compared to HT grafts [ 4 , 5 , 18 ]. Although some studies have reported no significant difference in re-rupture rates between HT and BTB grafts [ 1 , 2 ], a recent analysis using the Reverse Fragility Index —a novel metric for assessing the robustness of studies reporting non-significant results—revealed that many randomized controlled trials reporting no significant difference were vulnerable to statistical instability. Specifically, the reversal of outcomes in a small number of patients could lead to a significant difference, and in many cases, this number was smaller than the dropout rate, indicating that these findings may be fragile [ 19 ]. Although comparative studies of BTB and HT grafts focusing on high-risk patients, such as young females or highly active individuals, have been conducted [ 10 , 20 , 21 ], no studies have simultaneously adjusted for multiple confounding factors, such as posterior tibial slope, age, and sex, to compare BTB and HT grafts. Consistent with previous research, our results showed that in high-risk patients, the re-rupture rate was lower with BTB grafts compared to HT grafts. On the other hand, BTB grafts are associated with issues such as anterior knee pain (AKP) and reduced quadriceps strength during extension [ 22 , 23 ]. A recent study using New Zealand’s national registry also reported that while there was no significant difference in the KOOS pain subscore between HT and BTB grafts, the rate of severe kneeling difficulty was significantly higher in the BTB group (21.3%) compared to the HT group (9.4%) [ 24 ]. Given these BTB-specific complications, it is inappropriate to choose BTB grafts solely due to their lower re-rupture rate and comparable KOOS scores to HT grafts, without considering other important factors. Particularly, based on our findings, re-rupture rates and KOOS scores were comparable in patients with two or fewer risk factors. Therefore, for such patients, it is important to consider the patient’s background—including the type of sport, psychological state, and preoperative muscle strength—when selecting the most appropriate graft [ 6 , 25 ]. This study had several limitations. Firstly, this study was retrospective in nature. Secondly, there was a difference in the number of cases between the BTB and HT groups, which may have biased the results toward HT risk factors. It is possible that different results might have been obtained if risk factors specific to BTB had been investigated. Thirdly, AKP and postoperative muscle strength were not included as evaluation items. As previously mentioned, AKP and reduced quadriceps strength are notable issues with BTB grafts, and further comparative studies with HT grafts are warranted. Lastly, a considerable number of patients were lost to follow-up. The primary reason for this was that many of the patients were students, and follow-up became difficult due to relocation associated with advancing their education. Despite these limitations, our findings suggest that in situations where minimizing the risk of re-rupture is a critical concern, selecting BTB grafts over HT grafts for high-risk patients may result in a lower re-rupture risk, while maintaining KOOS scores comparable to HT grafts. This provides valuable clinical guidance for surgeons in making graft selection decisions. The clinical relevance of this study lies in proposing a potential strategy for graft selection based on individual risk profiles, thereby contributing to more personalized decision-making in ACL reconstruction. Conclusion In high-risk cases with an age of ≤ 20 years, PTS of ≥ 12°, and participation in pivoting sports, the re-rupture rate was significantly lower in the BTB group compared to the HT group, while clinical outcomes were comparable. However, after adjusting for risk factors, no significant differences were observed between the two groups in terms of re-rupture rates or clinical outcomes. Declarations Competing interests: The authors declare that they have no competing interests. Ethics approval: This study was approved by our institutional review board (IRB number: 2024-11). Consent to participate/publish : Written informed consent was obtained from the patients for participation of this cohort study. Written informed consent was obtained from the patients for publication of this cohort study and accompanying images. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author Contribution G.K. conceived of the presented idea. I.H. and S.T. developed the theory and performed the computations. G.K. and S.T. verified the analytical methods. I.H. encouraged G.K. to investigate this study and supervised the findings of this work. G.K. designed the study and wrote the initial draft of the manuscript. S.T. contributed to analysis and interpretation of data and assisted in the preparation of the manuscript. All other authors have contributed to data collection and interpretation, and critically reviewed the manuscript. I.H. conceived of the study and oversaw the overall direction and planning. All authors approved the final version of the manuscript and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Data availability: The datasets during and/or analysed during the current study available from the corresponding author on reasonable request. References Maletis GB, Inacio MC, Funahashi TT (2015) Risk factors associated with revision and contralateral anterior cruciate ligament reconstructions in the Kaiser Permanente ACLR registry. 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Available from: https://doi.org/10.1177/03635465221119787 Gifstad T, Foss OA, Engebretsen L et al (2014) Lower risk of revision with patellar tendon autografts compared with hamstring autografts: a registry study based on 45,998 primary ACL reconstructions in Scandinavia. Am J Sports Med 42(10):2319–2328. 10.1177/0363546514548164 Ruelos VCB, Masood R, Puzzitiello RN et al (2023) The reverse fragility index: RCTs reporting non-significant differences in failure rates between hamstring and bone-patellar tendon-bone autografts have fragile results. Knee Surg Sports Traumatol Arthrosc 31(8):3412–3419. 10.1007/s00167-023-07420-0 Rahardja R, Love H, Clatworthy MG et al (2021) Higher rate of return to preinjury activity levels after anterior cruciate ligament reconstruction with a bone-patellar tendon-bone versus hamstring tendon autograft in high-activity patients: results from the New Zealand ACL Registry. Am J Sports Med 49(13):3488–3494. 10.1177/03635465211044142 Salem HS, Varzhapetyan V, Patel N et al (2019) Anterior cruciate ligament reconstruction in young female athletes: patellar versus hamstring tendon autografts. Am J Sports Med 47(9):2086–2092. 10.1177/0363546519854762 Martorell-de Fortuny L, Torres-Claramunt R, Sánchez-Soler JF et al (2024) Patellar bone defect grafting does not reduce anterior knee pain after bone-patellar tendon-bone anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. Published online August 28, 2024. 10.1002/ksa.12449 Smith AH, Capin JJ, Zarzycki R, Snyder-Mackler L (2020) Athletes with bone-patellar tendon-bone autograft for anterior cruciate ligament reconstruction were slower to meet rehabilitation milestones and return-to-sport criteria than athletes with hamstring tendon autograft or soft tissue allograft: secondary analysis from the ACL-SPORTS trial. J Orthop Sports Phys Ther 50(5):259–266. 10.2519/jospt.2020.9111 Rahardja R, Love H, Clatworthy MG, Young SW (2023) Comparison of knee pain and difficulty with kneeling between patellar tendon and hamstring tendon autografts after anterior cruciate ligament reconstruction: a study from the New Zealand ACL Registry. Am J Sports Med 51(13):3464–3472. 10.1177/03635465231198063 DeFazio MW, Curry EJ, Gustin MJ et al (2020) Return to sport after ACL reconstruction with a BTB versus hamstring tendon autograft: a systematic review and meta-analysis. Orthop J Sports Med 8(12):2325967120964919. 10.1177/2325967120964919 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 02 Feb, 2026 Read the published version in Archives of Orthopaedic and Trauma Surgery → Version 1 posted Editorial decision: Revision requested 14 Oct, 2025 Reviews received at journal 28 Sep, 2025 Reviewers agreed at journal 27 Aug, 2025 Reviewers invited by journal 25 Aug, 2025 Editor assigned by journal 12 Jul, 2025 Submission checks completed at journal 12 Jul, 2025 First submitted to journal 11 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7099142","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":506553844,"identity":"3a1b6eb9-90ab-461f-bf35-1d66fb86e039","order_by":0,"name":"Kazumi Goto","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAy0lEQVRIiWNgGAWjYBACCTBpYGMAophJ0ZIG0sLYTIIWhsMkaJFsP/5M6kbBeWN5997njwsq7jDwt3cn4NUizZOQJp1jcNvM8Mxxw+YZZ54xSJw5uwGvFjmGhGMgLTaGM9IYm3nbDjMYSOQS0ML/sA2o5RwJWqQlktmAWg6YyUsQq0VyxjNm6xyDZGMDnmOMs3nOPOMh6BeJ8+kPb+f8sTOc397G8Jmn4o4cf3svfi1wYHAATB3gIU45CMg3QLQQr2MUjIJRMApGDAAADmREWK7zDHcAAAAASUVORK5CYII=","orcid":"","institution":"Kanto Rosai Hospital","correspondingAuthor":true,"prefix":"","firstName":"Kazumi","middleName":"","lastName":"Goto","suffix":""},{"id":506553845,"identity":"a8b59d19-ddd6-4da8-b9d7-905f3ada87eb","order_by":1,"name":"Eisaburo Honda","email":"","orcid":"","institution":"Kanto Rosai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Eisaburo","middleName":"","lastName":"Honda","suffix":""},{"id":506553846,"identity":"d175d5e1-3635-4e5a-b9d9-1bbb0bf9a8b9","order_by":2,"name":"Hiroshi Iwaso","email":"","orcid":"","institution":"Kanto Rosai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hiroshi","middleName":"","lastName":"Iwaso","suffix":""},{"id":506553847,"identity":"dc36f82e-6832-4e6b-a511-80a7b10fa8c3","order_by":3,"name":"Shin Sameshima","email":"","orcid":"","institution":"Kanto Rosai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shin","middleName":"","lastName":"Sameshima","suffix":""},{"id":506553848,"identity":"9073d562-2d38-480f-a0ed-925c6aeb2c04","order_by":4,"name":"Miyu Inagawa","email":"","orcid":"","institution":"Kanto Rosai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Miyu","middleName":"","lastName":"Inagawa","suffix":""},{"id":506553849,"identity":"efb8b51f-043f-4fb5-b6ad-ef1fd10e54c7","order_by":5,"name":"Yutaro Ishida","email":"","orcid":"","institution":"Kanto Rosai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yutaro","middleName":"","lastName":"Ishida","suffix":""},{"id":506553850,"identity":"00f680b5-9b98-457f-b003-0536a3566138","order_by":6,"name":"Koji Matsuo","email":"","orcid":"","institution":"Kanto Rosai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Koji","middleName":"","lastName":"Matsuo","suffix":""},{"id":506553851,"identity":"0c1b6979-f4ce-4787-8aef-e07b4b5010c4","order_by":7,"name":"Ryota Kuzuhara","email":"","orcid":"","institution":"Kanto Rosai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ryota","middleName":"","lastName":"Kuzuhara","suffix":""},{"id":506553852,"identity":"8f70d651-a7f2-4a20-ba35-9859ca5b8d9e","order_by":8,"name":"Takaki Sanada","email":"","orcid":"","institution":"Kanto Rosai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Takaki","middleName":"","lastName":"Sanada","suffix":""}],"badges":[],"createdAt":"2025-07-11 07:53:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7099142/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7099142/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00402-026-06196-5","type":"published","date":"2026-02-02T15:57:50+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":90472574,"identity":"fb3f890b-e3d1-434d-a424-f84377885215","added_by":"auto","created_at":"2025-09-03 06:35:26","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":345069,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart illustrating the criteria for inclusion in and exclusion from the study\u003c/p\u003e\n\u003cp\u003eACL, anterior cruciate ligament; BTB, bone patellar-tendon bone; HT, hamstring tendon; KL, Kellgren-Lawrence grading; PTS, posterior tibial slope\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7099142/v1/8bbfc32f26d187ecc920a107.jpeg"},{"id":90474260,"identity":"287c4862-42a2-41fd-9476-69d462568ad2","added_by":"auto","created_at":"2025-09-03 06:43:26","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":236382,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of propensity score matching\u003c/p\u003e\n\u003cp\u003eACLR, anterior cruciate ligament reconstruction; BTB, bone patellar-tendon bone; HT, hamstring tendon; KL, Kellgren-Lawrence grading; PTS, posterior tibial slope\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7099142/v1/f3a4e0be6b8a5d17b63ba433.jpeg"},{"id":102234114,"identity":"4c6a0350-04de-46d1-9a96-d16d1f2511fa","added_by":"auto","created_at":"2026-02-09 16:06:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1355277,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7099142/v1/1f2777db-edec-4ce9-bddc-1eeba06a704c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of Patellar Tendon and Hamstring Grafts in ACL Reconstruction: Patellar Tendon Shows Lower Re-Rupture Rates in High-Risk Groups but Comparable Outcomes in Low-Risk Patients","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRecent high-quality meta-analyses and national registry-based big data studies have established a consensus that bone patellar-tendon bone (BTB) autografts result in lower re-rupture rates compared to hamstring tendon (HT) autografts in primary anterior cruciate ligament (ACL) reconstruction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Although some studies report no statistically significant difference in re-rupture rates between BTB and HT grafts, most show consistently lower re-rupture rates with BTB [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This may be attributed to the stronger and faster graft incorporation of BTB compared to HT, as well as the intrinsic biomechanical properties of the graft itself [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Recently, BTB grafts have been increasingly favored over HT grafts in high-risk patients, such as those with generalized joint laxity or younger age [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This preference may be supported by evidence that patients with generalized joint laxity had a fourfold higher revision risk when HT grafts were used, compared to BTB grafts [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Despite growing attention to individualized graft selection based on risk assessment, no studies have directly compared re-rupture rates and clinical outcomes between these graft types according to patient risk profiles.\u003c/p\u003e\u003cp\u003eThe primary objective of this study was to compare re-rupture rates and clinical outcomes between BTB and HT autografts across different risk levels, in order to clarify differences in outcomes based on patient risk profiles. As a secondary objective, re-rupture rates and outcomes were compared between the two groups after adjusting for confounding factors, allowing for a comparison between patients with similar baseline characteristics. It was hypothesized that BTB grafts would result in lower re-rupture rates in high-risk patients, whereas no significant differences in re-rupture rates or clinical outcomes would be observed between the two graft types after adjustment for risk factors.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003ePatient selection\u003c/p\u003e\u003cp\u003eThis retrospective cohort study was approved by the institutional review board. Patients who underwent primary ACL reconstruction using either HT or BTB autografts between 2018 and 2022 were reviewed. Inclusion criteria were a minimum follow-up of two years. The exclusion criteria were as follows: previous ipsilateral knee injuries, osteoarthritis greater than Kellgren-Lawrence grade 3, contralateral ACL injuries during follow-up, and grade 3 concomitant collateral ligament injuries.\u003c/p\u003e\u003cp\u003eSurgical Indications and Technique\u003c/p\u003e\u003cp\u003eACL reconstruction was performed in patients diagnosed with primary ACL injury who either wished to return to sports or experienced instability that interfered with activities of daily living. The choice of graft type (HT or BTB) was determined by multiple operating surgeons based on individual preferences and patient-specific factors. For ACL reconstruction using HT, a double-bundle technique was employed. Femoral tunnels were primarily created using the modified transtibial technique [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], while the transportal or outside-in technique was also applied depending on the case. For ACL reconstruction using BTB grafts, femoral tunnels were created using the transportal technique with a rectangular method [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Graft fixation involved a suspensory device on the femoral side, while either a button or a post screw was used on the tibial side, depending on the surgeon\u0026rsquo;s preference. Using a tensioning device (Arthrex, Naples, FL, USA), the graft was fixed in a fully extended knee position with a tension ranging from 60 to 80 N. The tension was set to the level deemed optimal for the patient and confirmed intraoperatively with the pivot-shift test [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A standardized post-operative rehabilitation protocol was applied to all patients [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOutcome Measurements and MCID\u003c/p\u003e\u003cp\u003eThe following demographic and clinical parameters were extracted from medical records: age, sex, height, weight, laterality, time from injury to surgery, pre-operative sports type, pre-operative Tegner Activity Scale, presence of meniscal injury, knee hyperextension of 10\u0026deg;, generalized joint laxity (GJL), and posterior tibial slope angle (PTS). GJL was evaluated using an 8-level scoring system (0\u0026ndash;7) based on The University of Tokyo joint laxity test [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. PTS was measured on medial tibial slopes using radiographs, following the method described in previous research [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Pre-operative sports type was categorized as pivoting or non-pivoting according to prior studies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe primary outcome was defined as the presence or absence of re-rupture at two years postoperatively. Secondary outcomes included the evaluation of anteroposterior laxity using arthrometry, the Knee Injury and Osteoarthritis Outcome Score (KOOS) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and the Anterior Cruciate Ligament-Return to Sport Injury (ACL-RSI) scale [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Anteroposterior laxity was measured using the digital arthrometer device (Kneelax3; Monitored Rehab Systems, Haarlem, The Netherlands) by determining the difference between the surgical and healthy sides at 132 N with the knee flexed at 30\u0026deg; [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo assess clinical relevance, the minimal clinically important difference (MCID) for total KOOS score was calculated using a distribution-based method: one-half of the standard deviation (1/2 SD) of the change scores (Δ). The proportion of patients exceeding these thresholds was calculated for each group.\u003c/p\u003e\u003cp\u003eRisk Factors\u003c/p\u003e\u003cp\u003eBased on our previous research, age\u0026thinsp;\u0026le;\u0026thinsp;20 years, PTS\u0026thinsp;\u0026ge;\u0026thinsp;12 degrees, and preoperative participation in pivoting sports were hypothesized as risk factors [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. To validate the accuracy of this risk definition, logistic regression analysis was performed by including four additional factors: Graft type (BTB or HT), GJL, sex, and hyperextension of the knee, along with the original three risk factors. These additional variables were selected based on previous literature [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] reporting them as potential but controversial risk factors for graft re-rupture, with the aim of examining their significance within our cohort. As a result, the only significant independent risk factors were age\u0026thinsp;\u0026le;\u0026thinsp;20 years, PTS\u0026thinsp;\u0026ge;\u0026thinsp;12 degrees, and preoperative participation in pivoting sports, consistent with previous findings [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Therefore, these three factors were adopted as the risk criteria (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eResults of the logistic regression analysis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOdds Ratio\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95% CI Lower\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e95% CI Upper\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e(Intercept)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eInf\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.99\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex (male)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.98\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHT graft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.59\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGJL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.68\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHyperextension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eInf\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.99\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePivoting sports\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePTS\u0026thinsp;\u0026ge;\u0026thinsp;12\u0026deg;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u0026thinsp;\u0026le;\u0026thinsp;20 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eCI: confidence intervals; HT, hamstring tendon; GJL, generalized joint laxity; PTS, posterior tibial slope\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003ePatients with all three risk factors were defined as the high-risk group, and outcomes were compared between BTB and HT grafts within this group (Fig.\u0026nbsp;1). Additionally, for cases with two or fewer risk factors, propensity scores were calculated using five variables\u0026mdash;age\u0026thinsp;\u0026le;\u0026thinsp;20 years, PTS\u0026thinsp;\u0026ge;\u0026thinsp;12 degrees, preoperative participation in pivoting sports, surgical timing after injury, and preoperative Tegner Activity Scale\u0026mdash;which had shown significant between-group differences in baseline characteristics, and 1:1 matching was performed. Outcomes were then compared between the BTB and HT graft groups (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFigure 1.\u003c/p\u003e\u003cp\u003eFlowchart illustrating the criteria for inclusion in and exclusion from the study\u003c/p\u003e\u003cp\u003eACL, anterior cruciate ligament; BTB, bone patellar-tendon bone; HT, hamstring tendon; KL, Kellgren-Lawrence grading; PTS, posterior tibial slope\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFlowchart of propensity score matching\u003c/p\u003e\u003cp\u003eACLR, anterior cruciate ligament reconstruction; BTB, bone patellar-tendon bone; HT, hamstring tendon; KL, Kellgren-Lawrence grading; PTS, posterior tibial slope\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eStatistical Analyses\u003c/p\u003e\u003cp\u003eAll statistical analyses were performed using R software (version 4.2.1; R Development Core Team, Vienna, Austria). Mean values and standard deviations were used for continuous variables that showed a normal distribution, whereas medians and interquartile ranges were used for continuous variables that did not show a normal distribution. We used Student\u0026rsquo;s t-tests, Mann\u0026ndash;Whitney U tests, and chi-square tests to compare means, medians, and nominal variables, respectively, when comparing clinical outcomes, demographic variables, pre-operative variables, and intraoperative variables between the groups.\u003c/p\u003e\u003cp\u003eTo evaluate clinically meaningful improvement, the MCID for total KOOS score was calculated using a distribution-based method. Specifically, the MCID threshold was defined as one-half of the standard deviation (1/2 SD) of the change score (Δ\u0026thinsp;=\u0026thinsp;postoperative \u0026ndash; preoperative). The proportion of patients who met or exceeded this threshold was determined for each group and used for between-group comparisons.\u003c/p\u003e\u003cp\u003eA post hoc power analysis was performed to assess whether the sample size was sufficient to detect differences in the primary outcome (re-rupture rate) between the BTB and HT groups. Assuming an alpha level of 0.05 and the observed re-rupture rates in the high-risk group (12.9% for BTB and 35.7% for HT), the power to detect a statistically significant difference was 99.7%, indicating that the sample size in this subgroup was adequate.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 1,770 cases were screened. After applying exclusion criteria, 705 patients met the eligibility requirements and were included in the analysis (Fig.\u0026nbsp;1). The demographic data are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Overall, re-ruptures were observed in 37 out of 586 cases (6.3%) in the HT group and 12 out of 119 cases (10.1%) in the BTB group. In the high-risk group, the re-rupture rate was 15 out of 42 cases (35.7%) in the HT group and 4 out of 31 cases (12.9%) in the BTB group, with a statistically significant difference (p\u0026thinsp;=\u0026thinsp;0.03). The anteroposterior laxity difference between the surgical and healthy sides was 1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2 mm in the hamstring tendon group and 0.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4 mm in the BTB group (p\u0026thinsp;=\u0026thinsp;0.08). No statistically significant differences were observed in KOOS or ACL-RSI scores between the two groups at two years postoperatively (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The proportion of patients exceeding the MCID threshold for total KOOS score was also similar between the groups in the high-risk cohort (p\u0026thinsp;=\u0026thinsp;0.60).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatient demographics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHT (n\u0026thinsp;=\u0026thinsp;586)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBTB (n\u0026thinsp;=\u0026thinsp;119)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29.3\u0026thinsp;\u0026plusmn;\u0026thinsp;13.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex (female/male)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e324/262\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61/58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft/right\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e295/291\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61/58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.94\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeight (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e165.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e166.3\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.29\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBody weight (kg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62.6\u0026thinsp;\u0026plusmn;\u0026thinsp;11.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67.2\u0026thinsp;\u0026plusmn;\u0026thinsp;18.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical timing after injury (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e75 (48\u0026ndash;152)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52 (38\u0026ndash;87)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGeneralized joint laxity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (0\u0026ndash;7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (0\u0026ndash;7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHyperextension knee\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62 (11.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (18.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTegner Activity Scale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePivoting sports\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e346 (59.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e79 (66.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMM injury\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e190 (32.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (21.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLM injury\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e195 (33.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36 (30.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.59\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePosterior tibial slope angle (\u0026deg;)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eGeneralized joint laxity was scored using the University of Tokyo test (scores: 0\u0026ndash;7) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eHT, hamstring tendon: BTB, bone-patellar tendon-bone; MM, medial meniscus; LM, lateral meniscus\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison results in high-risk cases (patients with all three factors: age\u0026thinsp;\u0026le;\u0026thinsp;20 years, PTS\u0026thinsp;\u0026ge;\u0026thinsp;12\u0026deg;, and participation in pivoting sports)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHT (n\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBTB (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eRe-rupture, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (35.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (12.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eSex (female/male)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24/18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12/19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eLeft/right\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20/22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16/15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.82\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eHeight (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e165.0\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e167.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eBody weight (kg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.2\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e62.7\u0026thinsp;\u0026plusmn;\u0026thinsp;11.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eTegner Activity Scale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2-year KOOS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSymptom\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e93.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e97.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e97.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.78\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eADL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e99.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e99.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.64\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSports\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e92.8\u0026thinsp;\u0026plusmn;\u0026thinsp;16.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e94.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.76\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e91.2\u0026thinsp;\u0026plusmn;\u0026thinsp;16.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e88.8\u0026thinsp;\u0026plusmn;\u0026thinsp;13.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.61\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOverall\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e96.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e96.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.85\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e∆KOOS (overall)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.69\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eMCID (KOOS overall)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e77.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.60\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e2-year ACL-RSI score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e77.2\u0026thinsp;\u0026plusmn;\u0026thinsp;21.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e68.7\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eData are expressed as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations, and n (%)\u003c/p\u003e\u003cp\u003eHT, hamstring tendon: BTB, bone-patellar tendon-bone; 2-year KOOS, the 2-year postoperative Knee Injury and Osteoarthritis Outcome Score; MCID, minimal clinically important difference; ACL-RSI, Anterior Cruciate Ligament-Return to Sport Injury\u003c/p\u003e\u003cp\u003eAfter propensity score matching, re-ruptures occurred in 5 out of 73 cases (6.8%) in the HT group and 6 out of 73 cases (8.2%) in the BTB group, with no statistically significant difference (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The anteroposterior laxity difference between the surgical and healthy sides was 1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 mm in the HT group and 0.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 mm in the BTB group (p\u0026thinsp;=\u0026thinsp;0.81). No significant differences were found in KOOS or ACL-RSI scores between the two groups at two years postoperatively (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Similarly, the proportion of patients exceeding the MCID threshold for total KOOS score did not differ significantly between the groups after matching (p\u0026thinsp;=\u0026thinsp;0.99).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eDemographic data before and after propensity score matching\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003ePre-matching\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003ePost-matching\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHT (n\u0026thinsp;=\u0026thinsp;544)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBTB (n\u0026thinsp;=\u0026thinsp;88)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eHT (n\u0026thinsp;=\u0026thinsp;73)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eBTB (n\u0026thinsp;=\u0026thinsp;73)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30.3\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e23.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e22.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.63\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eSex (female/male)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e300/244\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e49/39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e42/31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e45/28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.61\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eLeft/right\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e275/269\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45/43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e39/34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e39/34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.99\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eHeight (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e165.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e165.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e165.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e164.9\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.92\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eBody weight (kg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e62.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e68.8\u0026thinsp;\u0026plusmn;\u0026thinsp;20.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e63.0\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e65.5\u0026thinsp;\u0026plusmn;\u0026thinsp;16.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.31\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eSurgical timing after injury (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76 (48\u0026ndash;152)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e52 (38\u0026ndash;87)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e67 (43\u0026ndash;127)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e54 (37\u0026ndash;108)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eGeneralized joint laxity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (0\u0026ndash;2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (0\u0026ndash;3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1 (0\u0026ndash;2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2 (0\u0026ndash;3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eHyperextension knee\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59 (12.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15 (18.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6 (8.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e14 (19.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eTegner Activity Scale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.91\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ePivoting sports\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e304 (56.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e48 (54.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e40 (54.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e45 (61.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eMM injury\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e183 (33.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18 (20.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e22 (30.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e15 (20.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eLM injury\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e184 (33.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28 (31.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e25 (34.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e21 (28.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.59\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ePosterior tibial slope angle (\u0026deg;)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e10.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.92\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eRe-rupture, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (4.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8 (9.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.054\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5 (6.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6 (8.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.99\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2-year KOOS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSymptom\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e90.4\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e90.4\u0026thinsp;\u0026plusmn;\u0026thinsp;9.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e91.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e90.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.45\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e94.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e94.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e95.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e94.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eADL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e98.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e99.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e98.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e99.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSports\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e91.6\u0026thinsp;\u0026plusmn;\u0026thinsp;12.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e89.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e92.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e90.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQOL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e84.9\u0026thinsp;\u0026plusmn;\u0026thinsp;16.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e85.9\u0026thinsp;\u0026plusmn;\u0026thinsp;16.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e87.8\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e86.7\u0026thinsp;\u0026plusmn;\u0026thinsp;16.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.71\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOverall\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e93.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e94.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e94.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e94.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.73\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e∆KOOS (overall)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.9\u0026thinsp;\u0026plusmn;\u0026thinsp;13.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e14.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e17.9\u0026thinsp;\u0026plusmn;\u0026thinsp;13.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eMCID (KOOS overall)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e85.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e82.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e82.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e80.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.99\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e2-year ACL-RSI score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63.7\u0026thinsp;\u0026plusmn;\u0026thinsp;22.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e67.2\u0026thinsp;\u0026plusmn;\u0026thinsp;19.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e68.4\u0026thinsp;\u0026plusmn;\u0026thinsp;21.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e67.0\u0026thinsp;\u0026plusmn;\u0026thinsp;19.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.77\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eData are expressed as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations, medians (interquartile ranges), and n (%)\u003c/p\u003e\u003cp\u003eGeneralized joint laxity was scored using the University of Tokyo test (scores: 0\u0026ndash;7) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eHT, hamstring tendon: BTB, bone-patellar tendon-bone; MM, medial meniscus; LM, lateral meniscus; 2-year KOOS, the 2-year postoperative Knee Injury and Osteoarthritis Outcome Score; MCID, minimal clinically important difference; ACL-RSI, Anterior Cruciate Ligament-Return to Sport Injury\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe most important finding in this study was that in patients with all three risk factors\u0026mdash;age\u0026thinsp;\u0026le;\u0026thinsp;20 years, PTS\u0026thinsp;\u0026ge;\u0026thinsp;12\u0026deg;, and participation in pivoting sports\u0026mdash;the re-rupture rate at two years postoperatively was significantly lower in the BTB graft group compared to the HT graft group. However, after adjusting for confounding factors, no significant difference in re-rupture rates was observed between the two graft types. Additionally, in both the high-risk group and the propensity score-matched cohort, no significant differences were found in KOOS or ACL-RSI scores between the two groups at two years postoperatively. Based on these results, it may be advisable for surgeons concerned about re-rupture risk to consider BTB grafts over HT grafts in high-risk patients.\u003c/p\u003e\u003cp\u003eNumerous studies have compared BTB and HT grafts, with a consensus that BTB grafts result in lower re-rupture rates compared to HT grafts [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Although some studies have reported no significant difference in re-rupture rates between HT and BTB grafts [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], a recent analysis using the Reverse Fragility Index \u0026mdash;a novel metric for assessing the robustness of studies reporting non-significant results\u0026mdash;revealed that many randomized controlled trials reporting no significant difference were vulnerable to statistical instability. Specifically, the reversal of outcomes in a small number of patients could lead to a significant difference, and in many cases, this number was smaller than the dropout rate, indicating that these findings may be fragile [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Although comparative studies of BTB and HT grafts focusing on high-risk patients, such as young females or highly active individuals, have been conducted [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], no studies have simultaneously adjusted for multiple confounding factors, such as posterior tibial slope, age, and sex, to compare BTB and HT grafts. Consistent with previous research, our results showed that in high-risk patients, the re-rupture rate was lower with BTB grafts compared to HT grafts.\u003c/p\u003e\u003cp\u003eOn the other hand, BTB grafts are associated with issues such as anterior knee pain (AKP) and reduced quadriceps strength during extension [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. A recent study using New Zealand\u0026rsquo;s national registry also reported that while there was no significant difference in the KOOS pain subscore between HT and BTB grafts, the rate of severe kneeling difficulty was significantly higher in the BTB group (21.3%) compared to the HT group (9.4%) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Given these BTB-specific complications, it is inappropriate to choose BTB grafts solely due to their lower re-rupture rate and comparable KOOS scores to HT grafts, without considering other important factors. Particularly, based on our findings, re-rupture rates and KOOS scores were comparable in patients with two or fewer risk factors. Therefore, for such patients, it is important to consider the patient\u0026rsquo;s background\u0026mdash;including the type of sport, psychological state, and preoperative muscle strength\u0026mdash;when selecting the most appropriate graft [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study had several limitations. Firstly, this study was retrospective in nature. Secondly, there was a difference in the number of cases between the BTB and HT groups, which may have biased the results toward HT risk factors. It is possible that different results might have been obtained if risk factors specific to BTB had been investigated. Thirdly, AKP and postoperative muscle strength were not included as evaluation items. As previously mentioned, AKP and reduced quadriceps strength are notable issues with BTB grafts, and further comparative studies with HT grafts are warranted. Lastly, a considerable number of patients were lost to follow-up. The primary reason for this was that many of the patients were students, and follow-up became difficult due to relocation associated with advancing their education. Despite these limitations, our findings suggest that in situations where minimizing the risk of re-rupture is a critical concern, selecting BTB grafts over HT grafts for high-risk patients may result in a lower re-rupture risk, while maintaining KOOS scores comparable to HT grafts. This provides valuable clinical guidance for surgeons in making graft selection decisions.\u003c/p\u003e\u003cp\u003eThe clinical relevance of this study lies in proposing a potential strategy for graft selection based on individual risk profiles, thereby contributing to more personalized decision-making in ACL reconstruction.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn high-risk cases with an age of \u0026le;\u0026thinsp;20 years, PTS of \u0026ge;\u0026thinsp;12\u0026deg;, and participation in pivoting sports, the re-rupture rate was significantly lower in the BTB group compared to the HT group, while clinical outcomes were comparable. However, after adjusting for risk factors, no significant differences were observed between the two groups in terms of re-rupture rates or clinical outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eCompeting interests:\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e\u003cp\u003eThis study was approved by our institutional review board (IRB number: 2024-11).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent to participate/publish\u003c/strong\u003e: Written informed consent was obtained from the patients for participation of this cohort study. Written informed consent was obtained from the patients for publication of this cohort study and accompanying images.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eG.K. conceived of the presented idea. I.H. and S.T. developed the theory and performed the computations. G.K. and S.T. verified the analytical methods. I.H. encouraged G.K. to investigate this study and supervised the findings of this work. G.K. designed the study and wrote the initial draft of the manuscript. S.T. contributed to analysis and interpretation of data and assisted in the preparation of the manuscript. All other authors have contributed to data collection and interpretation, and critically reviewed the manuscript. I.H. conceived of the study and oversaw the overall direction and planning. All authors approved the final version of the manuscript and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.\u003c/p\u003e\u003ch2\u003eData availability:\u003c/h2\u003e\u003cp\u003eThe datasets during and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMaletis GB, Inacio MC, Funahashi TT (2015) Risk factors associated with revision and contralateral anterior cruciate ligament reconstructions in the Kaiser Permanente ACLR registry. 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Orthop J Sports Med 8(12):2325967120964919. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/2325967120964919\u003c/span\u003e\u003cspan address=\"10.1177/2325967120964919\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"anterior cruciate ligament reconstruction, risk factor, posterior tibial slope, bone patellar-tendon bone, hamstring autograft","lastPublishedDoi":"10.21203/rs.3.rs-7099142/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7099142/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eTo compare re-rupture rates and clinical outcomes between bone\u0026ndash;patellar tendon\u0026ndash;bone (BTB) and hamstring tendon (HT) grafts in anterior cruciate ligament (ACL) reconstruction according to patient risk levels.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis retrospective cohort study included patients who underwent primary ACL reconstruction at a single institution between 2018 and 2022, with a minimum of two years of follow-up. High-risk patients were defined as those aged\u0026thinsp;\u0026le;\u0026thinsp;20 years, with posterior tibial slope\u0026thinsp;\u0026ge;\u0026thinsp;12\u0026deg;, and participating in pivoting sports. In this group, re-rupture rates and Knee injury and Osteoarthritis Outcome Score (KOOS) were compared between the BTB and HT grafts. For patients with two or fewer risk factors, propensity score matching was performed to compare outcomes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eIn the high-risk group, the BTB graft showed a significantly lower re-rupture rate compared to the HT graft (12.9% vs. 35.7%, p\u0026thinsp;=\u0026thinsp;0.03), with no significant difference in KOOS (96.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7 vs. 96.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3, p\u0026thinsp;=\u0026thinsp;0.85). In the lower-risk group after matching, the BTB graft showed a similar re-rupture rate compared to the HT graft (8.2% vs. 6.8%, p\u0026thinsp;=\u0026thinsp;0.99), with no significant difference in KOOS (94.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0 vs. 94.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6, p\u0026thinsp;=\u0026thinsp;0.73).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eBTB grafts reduced re-rupture rates compared to HT grafts in high-risk ACL reconstruction patients, while clinical outcomes were similar. In lower-risk patients, no significant differences were observed between graft types in either re-rupture rates or KOOS.\u003c/p\u003e\u003ch2\u003eLevel of Evidence\u003c/h2\u003e\u003cp\u003eLevel III\u003c/p\u003e","manuscriptTitle":"Comparison of Patellar Tendon and Hamstring Grafts in ACL Reconstruction: Patellar Tendon Shows Lower Re-Rupture Rates in High-Risk Groups but Comparable Outcomes in Low-Risk Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-03 06:35:22","doi":"10.21203/rs.3.rs-7099142/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-14T17:19:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-28T19:41:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"311394901120861110020971758420135340652","date":"2025-08-27T20:35:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-25T19:06:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-12T07:05:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-12T07:02:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Orthopaedic and Trauma Surgery","date":"2025-07-11T07:50:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"24cdbb51-2890-4e5f-a3b5-01ad6077064f","owner":[],"postedDate":"September 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T16:03:07+00:00","versionOfRecord":{"articleIdentity":"rs-7099142","link":"https://doi.org/10.1007/s00402-026-06196-5","journal":{"identity":"archives-of-orthopaedic-and-trauma-surgery","isVorOnly":false,"title":"Archives of Orthopaedic and Trauma Surgery"},"publishedOn":"2026-02-02 15:57:50","publishedOnDateReadable":"February 2nd, 2026"},"versionCreatedAt":"2025-09-03 06:35:22","video":"","vorDoi":"10.1007/s00402-026-06196-5","vorDoiUrl":"https://doi.org/10.1007/s00402-026-06196-5","workflowStages":[]},"version":"v1","identity":"rs-7099142","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7099142","identity":"rs-7099142","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}