Systematic Review

BoneePatellar TendoneBone Versus Soft-Tissue

Allograft for Anterior Cruciate Ligament
Reconstruction: A Systematic Review
Christopher D. Joyce, B.S., Kyle L. Randall, M.D., Michael W. Mariscalco, M.D.,
Robert A. Magnussen, M.D., M.P.H., and David C. Flanigan, M.D.

Purpose: To describe the outcomes of boneepatellar tendonebone (BPTB) and soft-tissue allografts in anterior cruciate
ligament (ACL) reconstruction with respect to graft failure risk, physical examination ndings, instrumented laxity, and
patient-reported outcomes. Methods: A search of the PubMed, Scopus, CINAHL (Cumulative Index to Nursing and
Allied Health Literature) Complete, Cochrane Collaboration, and SPORTDiscus databases was performed. Englishlanguage studies with outcome data on primary ACL reconstruction with nonirradiated BPTB and soft-tissue allografts
were identied. Outcome data included failure risk, physical examination ndings, instrumented laxity measurements,
and patient-reported outcome scores. Results: Seventeen studies met the inclusion criteria. Of these studies, 11 reported
on BPTB allografts exclusively, 5 reported on soft-tissue allografts exclusively, and 1 compared both types. The
comparative study showed no difference in failure risk, Lachman grade, pivot-shift grade, instrumented laxity, or overall
International Knee Documentation Committee score between the 2 allograft types. Data from all studies yielded a failure
risk of 10.3% (95% condence interval [CI], 4.5% to 18.1%) in the soft-tissue group and 15.2% (95% CI, 11.3% to
19.6%) in the BPTB group. The risk of a Lachman grade greater than 5 mm was 6.4% (95% CI, 1.7% to 13.7%) in the
soft-tissue group and 8.6% (95% CI, 6.3% to 11.2%) in the BPTB group. The risk of a grade 2 or 3 pivot shift was 1.4%
(95% CI, 0.3% to 3.3%) in the soft-tissue group and 4.1% (95% CI, 1.9% to 7.2%) in the BPTB group.
Conclusions: One comparative study showed no difference in results after ACL reconstruction with nonirradiated BPTB
and soft-tissue allografts. Inclusion of case series in the analysis showed qualitatively similar outcomes with the 2 graft
types. Level of Evidence: Level IV, systematic review of Level III and IV studies.

umerous techniques and graft choices have been

described for reconstruction of the anterior cruciate ligament (ACL). Surgeon or patient preference,
surgeon experience, and patient age and activity level
all play a role in graft choice (autograft v allograft). The
use of allografts has increased in recent years because
they offer less donor-site morbidity, a decreased operative time, and an unlimited graft source in the setting
of multiligament and revision reconstructions.1-4

From The Ohio State University Sports Medicine Center and Cartilage
Restoration Program, Columbus, Ohio, U.S.A.
The authors report the following potential conict of interest or source of
funding: D.C.F. receives support from Smith&Nephew, Vericel, and DePuy Mitek.
Received September 29, 2014; accepted August 4, 2015.
Address correspondence to David C. Flanigan, M.D., The Ohio State University Sports Medicine Center and Cartilage Restoration Program, 2050
Kenny Rd, Ste 3100, Columbus, OH 43221, U.S.A. E-mail: david.anigan@
osumc.edu
2015 by the Arthroscopy Association of North America
0749-8063/14820/$36.00
http://dx.doi.org/10.1016/j.arthro.2015.08.003

However, allografts are associated with a higher

expense, a risk of disease transmission, and an
increased risk of graft rupture in the younger, more
active population.3,5-7
There have been numerous systematic reviews
comparing the results of autograft hamstring versus
boneepatellar tendonebone (BPTB) grafts.8,9 A recent
meta-analysis by Mohtadi et al.8 is representative of the
typical ndings and noted that there was insufcient
evidence to recommend one graft choice over the
other. Although data from this analysis suggested that
patellar tendon autografts produce a more statically
stable knee, they were associated with more anterior
knee problems.
There have also been many studies comparing ACL
autograft with allograft.10-14 Prodromos et al.14 showed
that the overall stability rate was 72% for all autografts
compared with 59% for all allografts (P < .001), which
did not account for the effect of irradiation on the
allograft tissue. Mariscalco et al.13 compared exclusively
nonirradiated allograft tissue with autograft in a

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol

-,

No

(Month), 2015: pp 1-9

C. D. JOYCE ET AL.

systematic review and concluded that there was no

signicant difference between the 2 graft sources in
outcomes.
The aim of this article is to describe the results of
BPTB allografts and soft-tissue allografts for ACL
reconstruction. We hypothesize that BPTB and softtissue allografts show no difference in (1) graft failure
risk, (2) laxity on postoperative physical examination,
(3) instrumented laxity, or (4) patient-reported
outcome scores after ACL reconstruction.

Methods
Literature Search and Study Selection
A review of the literature was performed by 2 authors
(C.J. and M.M.) using the PubMed, Scopus, CINAHL
(Cumulative Index to Nursing and Allied Health Literature) Complete, Cochrane Collaboration, and SPORTDiscus databases through April 10, 2014. The search
terms used were anterior cruciate ligament, allograft, and [patellar OR soft tissue OR hamstring
OR semitendinosus OR tibialis OR peroneus OR
iliotibial OR fascia lata OR Achilles]. Completion of
the search in each database resulted in a list of 1,579 titles. After removal of all duplicate studies (407), 1,172
titles remained. Articles were excluded according to our
inclusion and exclusion criteria as outlined in Table 1,
yielding 22 potential articles for inclusion in the review.
Seven articles did not mention whether the grafts were
irradiated or nonirradiated, and an attempt was made to
contact the corresponding author for each article. Five
authors did not reply, and these studies were excluded.
Seventeen studies remained and were included in this
review. The literature search is summarized in Figure 1.
Table 1. Inclusion and Exclusion Criteria
Inclusion criteria
Published prospective series describing outcomes of ACL
reconstruction using allograft
Minimum follow-up of 2 yr
Reconstruction with patellar tendon or soft-tissue allograft
Use of nonirradiated graft
Exclusion criteria
Laboratory or animal studies
Follow-up <2 yr
Use of graft tissue other than patellar tendon or soft-tissue allograft
Use of irradiated graft
Unclear graft type or irradiation
Use of fascia lata graft
Use of Achilles allograft
Animal studies
Reviews without original data
Nonepeer-reviewed studies
ACL, anterior cruciate ligament.

Fig 1. Search strategy and results. (CINAHL, Cumulative Index to Nursing and Allied Health Literature.)

Data Extraction
Two authors independently extracted data from the
17 studies included in this systematic review. Study
descriptive data included country of origin, procedure
date range, level of evidence, number of surgeons,
allograft type, surgical approach, and femoral and tibial
xation method. Patient demographic data included
age, sex, length of follow-up, and follow-up percentage.
Outcome data included Lachman grade, pivot-shift
grade, overall International Knee Documentation
Committee (IKDC) score, Lysholm score, Tegner score,
and rerupture risk.
Quality Appraisal
Two authors independently determined the methodologic quality of each study separately using the
Delphi list quality score15 and the modied Coleman
methodology score.14 The Delphi list uses 9 questions to
score the quality assessment: Was a method of
randomization used? Was the treatment allocation
concealed? Were the groups similar at baseline? Was
eligibility criteria specied? Was the outcome assessor
blinded? Was the care provider blinded? Was the patient blinded? Were point estimates and measures of
variability used? Was there an intention-to-treat analysis? In this assessment, each study was given 1 point
for yes, a 1-point deduction for no, and 0 points for
dont know.15 The modied Coleman score is determined by study size, mean follow-up, percentage of
patients with follow-up, number of interventions per
group, study type, diagnostic certainty of ACL tear,
description of ACL reconstruction procedure, description of postoperative rehabilitation, specications of

ALLOGRAFT COMPARISON
Table 2. Study Description
Author
BPTB allograft
Bach et al.16
Barrett et al.17
Barrett et al.18
Kleipool et al.21
Lee et al.32
Melberg and Indelicato19
Nin et al.20
Noyes and Barber-Westin22
Peterson et al.23
Siebold et al.24
Sun et al.26
Sun et al.25
Soft-tissue allograft
Almqvist et al.31
Lawhorn et al.27
Lee et al.32
Snow et al.28
Sun et al.29
Sun et al.30

Journal

Year

Country

Procedure Date Range

Level of Evidence

AJSM
AJSM
Arthroscopy
KSSTA
Arthroscopy
SMAR
KSSTA
JBJS
Arthroscopy
AOTS
KSSTA
Arthroscopy

2005
2005
2010
1998
2010
1993
1996
1996
2001
2003
2009
2009

US
US
US
Netherlands
Republic of Korea
US
Spain
US
US
Germany
China
China

1986-2000
1994-2000
1993-2005
1989-1991
2000-2002
1985-1992
1988-1996
1986-1987
1991-1992
1993-1998
2004-2006
2000-2004

IV
IV
IV
IV
III
IV
IV
IV
IV
IV
IV
IV

KSSTA
Arthroscopy
Arthroscopy
KSSTA
AJSM
KSSTA

2009
2012
2010
2010
2011
2012

Belgium
US
Republic of Korea
England
China
China

1995-1997
2002-2006
2002-2005
NR
2000-2004
2005-2008

IV
IV
III
IV
IV
IV

AJSM, American Journal of Sports Medicine; AOTS, Archives of Orthopaedic and Trauma Surgery; BPTB, boneepatellar tendonebone; JBJS, Journal of
Bone & Joint Surgery; KSSTA, Knee Surgery, Sports Traumatology, Arthroscopy; NR, not reported; SMAR, Sports Medicine and Arthroscopy Review.

outcome criteria, procedures for assessing outcomes,

and description of patient selection process.14 The
maximum possible modied Coleman score is 100
points, with 85 to 100 points being considered excellent; 70 to 84 points, good; 55 to 69 points, fair; and 54
points or less, poor.
Statistical Methods
Data extracted and compiled from the BPTB allograft
studies were compared with data extracted and
compiled from the soft-tissue allograft studies. Data for
each graft type were combined using a random-effects
model by the method of DerSimonian-Laird to calculate an overall pooled estimate of failure risk, Lachman
grade greater than 5 mm, and grade 2 or 3 pivot shift
for each graft type.

Results
Study Characteristics
Seventeen studies meeting the inclusion criteria
were reviewed: 11 reported on BPTB allografts exclusively,16-26 5 reported on soft-tissue allografts exclusively (2 hamstring, 2 tibialis anterior, and 1 tibialis
anterior and posterior),27-31 and 1 compared both allograft types.32 The level of evidence was determined as
related to our research question. One study included
Level III evidence,32 and the remaining 16 studies
included Level IV evidence16-31 (Table 2). All grafts used
in the BPTB group were nonirradiated, fresh-frozen
BPTB allografts. In the soft-tissue group, all ACL reconstructions were performed with nonirradiated,
fresh-frozen allografts. The surgical technique for each

article, including number of surgeons, approach,

and femoral and tibial xation method, is reported in
Table 3.
Demographic Characteristics
The mean age of the patients who underwent BPTB
allograft placement was 32.4 years (range, 13 to 69
years), and the mean age for soft-tissue allograft patients was 29.2 years (range, 15 to 60 years). The mean
length of follow-up was 46.9 months (range, 9 to 194
months) in the BPTB group and 57.6 months (range, 24
to 120 months) in the soft-tissue group. The BPTB
group contained 61.8% male and 38.2% female patients (we excluded 1 study that did not report sex22),
and the soft-tissue group contained 76.6% male and
23.4% female patients. The soft-tissue group contained
a higher proportion of male patients, and the overall
follow-up percent was higher in the soft-tissue group,
at 84.5%, compared with the BPTB group, at 77.9%
(Table 4).
Qualitative Appraisal
Methodologic quality scores for each article were
compiled using the Delphi list and modied Coleman
scores (Table 4). The average modied Coleman score
for all 17 studies was 66.6 points. According to the
stratication, there were 3 studies of excellent quality, 3
of good quality, 8 of fair quality, and 3 of poor quality.
Comparative Study
The 1 identied study that directly compared outcomes between BPTB and soft-tissue allografts showed
no difference in failure risk, Lachman grade, pivot-shift

C. D. JOYCE ET AL.

Table 3. Surgical Details

Author
BPTB allograft
Bach et al.16 (2005)

No. of
Surgeons

Allograft Type

Approach

BPTB

Barrett et al.17 (2005)

BPTB

Endoscopic (56),
dual incision (3)
Endoscopic

Barrett et al.18 (2010)

Kleipool et al.21 (1998)
Lee et al.32 (2010)
Melberg and Indelicato19
(1993)
Nin et al.20 (1996)

1
1
1
1

BPTB
BPTB
BPTB
BPTB

Endoscopic
Endoscopic
Endoscopic
Endoscopic

BPTB

BPTB

Endoscopic (40),
dual incision (20)
Mini-arthrotomy
(18), endoscopic
(10)
Endoscopic
Endoscopic
Endoscopic
Endoscopic

Noyes and Barber-Westin22

(1996)

Femoral Fixation
Interference screw

Interference screw

Interference screw
(33), button (2),
button-screw
combination (3)
NR
Interference screw
Interference screw
Interference screw

Interference screw/post
(36), button (2)

NR
Interference screw
Interference screw
Interference screw

Press t

Screw and washer

NR

NR

Peterson et al.23 (2001)

Siebold et al.24 (2003)
Sun et al.26 (2009, KSSTA)
Sun et al.25 (2009,
Arthroscopy)
Soft-tissue allograft
Almqvist et al.31 (2009)

1
NR
1
1

BPTB
BPTB
BPTB
BPTB

NR

Tibialis anterior,
posterior

Endoscopic

Lawhorn et al.27 (2012)

Lee et al.32 (2010)

5
1

Tibialis anterior
Tibialis anterior

Endoscopic
Endoscopic

NR

Tibialis anterior

NR

Doubled
hamstring
Doubled
hamstring

Endoscopic

EndoButton (Smith &

Nephew Endoscopy,
Andover, MA)
EndoButton

Endoscopic

EndoButton

Snow et al.28 (2010)

Sun et al.29 (2011)

Sun et al.30 (2012)

Tibial Fixation

Interference
Interference
Interference
Interference

screw
screw
screw
screw

Mitek anchors
(DePuy Synthes,
Warsaw, IN)
Cross pin
Cross pin

Interference
Interference
Interference
Interference

screw
screw
screw
screw

Interference screw and

staple
Screw and spiked washer
Interference screw and
staple
Interference screw and
staple
Interference screw and
staple
Interference screw

BPTB, boneepatellar tendonebone; KSSTA, Knee Surgery, Sports Traumatology, Arthroscopy; NR, not reported.

grade, instrumented laxity, or overall IKDC score between the 2 allograft types.32
Failure Risk Across All Studies
Clinical failure risk was determined using an algorithm described by Crawford et al.33 This standardized
failure risk is dened by the following: grade 2 or
worse Lachman, grade 2 or worse pivot shift, overall
IKDC grade C or D, or instrumented laxity with a sideto-side difference greater than 5 mm. In addition, patients with ruptured grafts were not included in the
data from 3 studies,16,21,22 and thus the patients with
ruptured grafts were added to the clinical failure risk to
produce a redened cumulative failure risk. Six studies
did not report the graft rupture risk.17,19,25,26,29,30 The
redened cumulative failure risk in patients with softtissue allografts is reported in Table 5. The pooled
failure risk was 10.3% (95% condence interval [CI],

4.5% to 18.1%) in the soft-tissue allograft group

(Fig 2) and 15.2% (95% CI, 11.3% to 19.6%) in the
BPTB allograft group (Fig 3).
Laxity on Physical Examination Across All Studies
Laxity on physical examination was determined
with Lachman and pivot-shift testing at follow-up.
Lachman testing was reported in 9 BPTB studies and
3 soft-tissue studies (Table 6). The pooled risk of a
Lachman grade greater than 5 mm was 6.4% (95%
CI, 1.7% to 13.7%) in the soft-tissue allograft group
and 8.6% (95% CI, 6.3% to 11.2%) in the BPTB
allograft group. Pivot-shift testing was reported in 9
BPTB studies and 4 soft-tissue studies (Table 7). The
pooled risk of a grade 2 or 3 pivot shift was 1.4%
(95% CI, 0.3% to 3.3%) in the soft-tissue allograft
group and 4.1% (95% CI, 1.9% to 7.2%) in the BPTB
allograft group.

ALLOGRAFT COMPARISON
Table 4. Study Demographic Characteristics and Follow-Up

Author
BPTB allograft
Bach et al.16 (2005)
Barrett et al.17 (2005)
Barrett et al.18 (2010)
Kleipool et al.21 (1998)
Melberg and Indelicato19
(1993)
Lee et al.32 (2010)
Nin et al.20 (1996)
Noyes and Barber-Westin22
(1996)
Peterson et al.23 (2001)
Siebold et al.24 (2003)
Sun et al.26 (2009, KSSTA)
Sun et al.25 (2009, Arthroscopy)
Soft-tissue allograft
Almqvist et al.31 (2009)
Lawhorn et al.27 (2012)
Lee et al.32 (2010)
Snow et al.28 (2010)
Sun et al.29 (2011)
Sun et al.30 (2012)

No. of
Patients

Mean Age
(Range), yr

Mean Length of
Follow-Up
(Range), mo

Sex

3
5
7
6
5

55
55
53
69
53

39 (24-96)
47 (24-78)
84 (60-108)

NR
59
100

3
5
3

56
56
68

63
90
100
93

6
5
1
2

56
74
86
94

3
3
3
3
3
1

72
69
56
48
94
84

60
60
28

27.9 (13-60)
23 (16-32)
23 (14-51)

51 M and 9 F
34 M and 26 F
NR

30
183
34
80

28
39.8
31.8
33

(15-55)
(20-69)
(19-64)
(19-65)

19 M and 11 F
120 M and 63 F
22 M and 12 F
63 M and 17 F

62.5
39
27.3
67

50
48
153
64
95
38

25
33.3
28.6
27
31
31.7

(17-50)
(16-53)
(15-60)
(16-55)
(18-59)
(21-56)

36 M and 14 F
38 M and 10 F
127 M and 26 F
33 M and 31 F
78 M and 17 F
31 M and 7 F

NR (120-144)y
24
34 (24-52)
44.5 (24-55)
95 (72-120)
42.1 (31-55)

M
M
M
M
M

and
and
and
and
and

38
18
48
19
26

F
F
F
F
F

Modied Coleman
Methodology Score

66
100
70
92
43

41
47
28.1
28
25

21
20
30
17
67

Delphi
Score

(26-170)
(24-74)
(9-194)
(30-64)
(24-51)

59*
38
78
36
93

(18-61)
(40-58)
(13-39)
(14-43)
(14-49)

%
Follow-Up

51
36.4
62.7
46
30

(55-73)
(24-74)
(14-44)
(50-96)

83.3
65.7
NR
87.7
91
97.4

BPTB, boneepatellar tendonebone; F, female; KSSTA, Knee Surgery, Sports Traumatology, Arthroscopy; M, male; NR, not reported.
*One patient underwent bilateral ACL repairs (59 patients, 60 knees).
y
For average calculation, a follow-up time of 120 months was used.

Instrumented Laxity Across All Studies

Laxity was measured with either a KT-1000 or KT2000 arthrometer (MEDmetric, San Diego, CA) in 10
BPTB studies and 5 soft-tissue studies (Table 8). The
pooled risk of instrumented anteroposterior laxity
greater than 5 mm was 4.4% (95% CI, 0.6% to 11.6%)
in the soft-tissue allograft group and 4.9% (95% CI,
2.8% to 7.4%) in the BPTB allograft group.
Overall IKDC Score Across All Studies
Eight BPTB studies and 4 soft-tissue studies used the
objective IKDC scoring system to describe the results of
the ACL reconstruction as normal (A), nearly normal
(B), abnormal (C), and severely abnormal (D)
(Table 9). The pooled risk of having an overall IKDC
score of C or D was 6.5% (95% CI, 2.4% to 12.4%) in
the soft-tissue allograft group and 12.2% (95% CI,
9.3% to 15.3%) in the BPTB allograft group.
Patient-Reported Outcome Scores Across All
Studies
Mean Lysholm scores at follow-up ranged from 88 to
90 in the soft-tissue allograft group and from 82 to 94 in
the BPTB allograft group. Mean Tegner scores at followup ranged from 6.5 to 7.6 in the soft-tissue allograft
group and from 4.1 to 7.6 in the BPTB allograft group
(Table 10).

Discussion
Although both BPTB and soft-tissue allografts are
used in clinical practice, this systematic review identied only 1 study in the literature that directly compared
these grafts. The study showed no signicant differences in any outcome variable between the 2 grafts.32
Expansion of this systematic review to include the
Level IV evidence available on this topic showed qualitatively similar ndings to the 1 comparative study on
this topic. By pooling data from all available studies of
the outcomes of ACL reconstruction with nonirradiated
allograft, we constructed 95% CIs for the risk of graft
failure, increased knee anteroposterior and rotational
laxity, and fair/poor overall IKDC scores. Although
direct statistical comparison of these studies is precluded
by potential differences in patient populations, the
overlap between the calculated CIs lends support to the
ndings of the comparative study that the choice of
nonirradiated allograft (soft tissue v BPTB) is likely not a
major determinant of outcomes.
There are additional studies in the literature
comparing allograft types that were not included in our
review because of the inclusion and exclusion criteria.
A recent study by OBrien et al.34 compared nonirradiated BPTB allografts with doubled tibialis anterior
allografts in patients younger than 30 years. The study
was a retrospective matched-pair comparison with 20

Table 5. Failure Risk

Stated
Rerupture
Rate

Abnormal
Lachman
Grade

Abnormal
Pivot-Shift
Grade

Abnormal
Instrumented
Laxity

IKDC
Overall
Grade C or D

61
38
78
37
93

1/61
NR
12/78
1/37
NR

4/60
1/38
NR
5/36
10/93

1/60
1/38
NR
3/36
7/93

0/60
3/38
NR
2/36
4/93

0/60
5/38
NR
6/36
7/93

4/60
5/38
19/78
6/36
7/60

60
60
30

5/60
0/60
2/30

2/60
6/60
NR

2/60
6/60
NR

NR
NR
1/28

7/60
9/60
6/28

10/93 (10.8%)
9/60 (15%)
6/28 (21.4%)

10/93 (10.8%) (95% CI, 5.3%-18.9%)

9/60 (15%) (95% CI, 7.1%-26.6%)
8/30 (26.7%) (95% CI, 12.3%-45.9%)

30
183
34
80

1/30
19/183
NR
NR

3/30
NR
3/34
6/80

1/30
NR
0/34
0/80

0/30
8/164
3/34
6/80

NR
26/164
3/34
5/80

3/30 (10%)
45/183 (24.6%)
3/34 (8.8%)
6/80 (7.5%)

3/30 (10%) (95% CI, 2.1%-26.5%)

45/183 (24.6%) (95% CI, 18.5%-31.5%)
3/34 (8.8%) (95% CI, 1.9%-23.7%)
6/80 (7.5%) (95% CI, 2.8%-15.6%)

55
48
153
64
95
38

5/55
0/48
5/153
5/64
NR
NR

NR
NR
3/153
NR
8/95
4/38

NR
0/48
4/153
1/25
0/95
0/38

NR
0/48
NR
0/25
8/95
4/38

11/50
0/48
11/153
3/59
9/95
4/38

11/50 (22%)
0/48 (0%)
11/153 (7.2%)
8/64 (12.5%)
9/95 (9.5%)
4/38 (10.5%)

16/55 (29.1%) (95% CI, 17.6%-42.9%)

0/48 (0%) (95% CI, 0.0%-7.4%)
11/153 (7.2%) (95% CI, 3.6%-12.5%)
8/64 (12.5%) (95% CI, 5.6%-23.2%)
9/95 (9.5%) (95% CI, 4.4%-17.2%)
4/38 (10.5%) (95% CI, 2.9%-24.8%)

Clinical
Failure*
(6.7%)
(13.2%)
(24.4%)
(16.7%)
(11.7%)

Redened Cumulative Failure Risk

5/61
5/38
19/78
7/37
7/60

(8.2%) (95% CI, 2.7%-18.1%)

(13.2%) (95% CI, 4.4%-28.1%)
(24.4%) (95% CI, 15.3%-35.4%)
(18.9%) (95% CI, 8.0%-35.2%)
(11.7%) (95% CI, 4.8%-22.6%)

BPTB, boneepatellar tendonebone; CI, condence interval; IKDC, International Knee Documentation Committee; KSSTA, Knee Surgery, Sports Traumatology, Arthroscopy; NR, not reported.
*Clinical failure risk as dened by Crawford et al.33

C. D. JOYCE ET AL.

Author
BPTB allograft
Bach et al.16 (2005)
Barrett et al.17 (2005)
Barrett et al.18 (2010)
Kleipool et al.21 (1998)
Melberg and Indelicato19
(1993)
Lee et al.32 (2010)
Nin et al.20 (1996)
Noyes and Barber-Westin22
(1996)
Peterson et al.23 (2001)
Siebold et al.24 (2003)
Sun et al.26 (2009, KSSTA)
Sun et al.25 (2009, Arthroscopy)
Soft-tissue allograft
Almqvist et al.31 (2009)
Lawhorn et al.27 (2012)
Lee et al.32 (2010)
Snow et al.28 (2010)
Sun et al.29 (2011)
Sun et al.30 (2012)

No. of
Patients

ALLOGRAFT COMPARISON
Table 6. Lachman Grade at Follow-Up

Fig 2. Forest plot showing risk of graft failure after anterior

cruciate ligament reconstruction with soft-tissue allograft. The
overall pooled risk of graft failure is 10.3% (95% condence
interval, 4.5% to 18.1%).

patients in each group; however, follow-up was less

than 2 years. The authors showed no signicant difference between the 2 grafts with respect to graft
rupture risk or patient-reported outcomes. Noyes
et al.35 studied BPTB allografts and fascia lata allografts
in a prospective study that concluded that BPTB allografts had signicantly lower anteroposterior displacement with KT-1000 testing than fascia lata allografts.
There was no signicant difference in the nal rating
between the 2 groups. No direct comparison was made
between the 2 groups regarding physical examination
ndings or graft failure risk. The authors concluded that
BPTB allografts were more effective at restoring anteroposterior translation than fascia lata grafts because of
rmer xation of the osseous portion of the graft. The
BPTB patients from their study were included in a later
study by Noyes and Barber-Westin22 with longer
follow-up that is included in this review. The patients
with fascia lata grafts were not included in this review.

Author
BPTB allograft
Bach et al.16 (2005)
Barrett et al.17 (2005)
Kleipool et al.21 (1998)
Melberg and Indelicato19 (1993)
Lee et al.32 (2010)
Nin et al.20 (1996)
Peterson et al.23 (2001)
Sun et al.26 (2009, KSSTA)
Sun et al.25 (2009, Arthroscopy)
Soft-tissue allograft
Lee et al.32 (2010)
Sun et al.29 (2011)
Sun et al.30 (2012)

Grade

No. of
Patients

60
38
36
93
60
60
30
34
80

39
31
21
47
53
43
24
28
65

17
6
10
36
5
11
3
3
9

4
1
5
6
2
6
3
3
6

0
0
0
4
0
0
0
0
0

153
95
38

139
78
30

11
9
4

3
8
4

0
0
0

BPTB, boneepatellar tendonebone; KSSTA, Knee Surgery, Sports

Traumatology, Arthroscopy.

One strength of our study is that it is the only systematic review comparing nonirradiated soft-tissue allografts with BPTB allografts in the literature. The
ndings of this study, including the estimated risks of
failure and poor outcomes, may not apply when irradiated tissue is used for ACL reconstruction. A second
strength is the standardized and comprehensive
manner in which this review was conducted.
Limitations
The study does have signicant limitations. One limitation is the relatively small number of studies reporting
on soft-tissue allografts (6 studies) compared with BPTB
allografts (12 studies), leading to the inclusion of more
patients with BPTB allografts in this review. Furthermore, concomitant intra-articular injuries varied greatly
among the studies, potentially altering the outcomes of
Table 7. Pivot-Shift Grade at Follow-Up

Fig 3. Forest plot showing risk of graft failure after anterior

cruciate ligament reconstruction with boneepatellar tendonebone allograft. The overall pooled risk of graft failure is
15.2% (95% condence interval, 11.3% to 19.6%). (KSSTA,
Knee Surgery, Sports Traumatology, Arthroscopy.)

Author
BPTB allograft
Bach et al.16 (2005)
Barrett et al.17 (2005)
Kleipool et al.21 (1998)
Lee et al.32 (2010)
Melberg and Indelicato19 (1993)
Nin et al.20 (1996)
Peterson et al.23 (2001)
Sun et al.26 (2009, KSSTA)
Sun et al.25 (2009, Arthroscopy)
Soft-tissue allograft
Lawhorn et al.27 (2012)
Lee et al.32 (2010)
Snow et al.28 (2010)
Sun et al.29 (2011)
Sun et al.30 (2012)

Grade

No. of
Patients

60
38
36
60
93
60
30
34
80

54
34
28
53
63
43
25
31
74

5
3
5
5
23
11
4
3
6

0
1
3
2
7
6
1
0
0

1
0
0
0
0
0
0
0
0

48
153
25
95
38

44
137
18
87
34

4
12
6
8
4

0
4
1
0
0

0
0
0
0
0

BPTB, boneepatellar tendonebone; KSSTA, Knee Surgery, Sports

Traumatology, Arthroscopy.

C. D. JOYCE ET AL.

Table 8. Instrumented Laxity Measurements

Table 10. Postoperative Patient-Reported Outcome Scores

Side-to-Side
Difference

Author
BPTB allograft
Bach et al.16 (2005)
Barrett et al.17 (2005)
Kleipool et al.21 (1998)
Melberg and Indelicato19 (1993)
Noyes and Barber-Westin22 (1996)
Peterson et al.23 (2001)
Siebold et al.24 (2003)
Sun et al.26 (2009, KSSTA)
Sun et al.25 (2009, Arthroscopy)
Soft-tissue allograft
Lawhorn et al.27 (2012)
Snow et al.28 (2010)
Sun et al.29 (2011)
Sun et al.30 (2012)

No. of
Patients

<3
mm

3-5
mm

>5
mm

60
38
36
93
28
30
164
34
80

57
33
27
80
23
22
107
29
67

3
2
7
9
4
8
49
2
7

0
3
2
4
1
0
8
3
6

48
25
95
38

43
15
78
32

5
10
9
2

0
0
8
4

NOTE. Instrumented laxity was measured with either a KT-1000 or

KT-2000 arthrometer.
BPTB, boneepatellar tendonebone; KSSTA, Knee Surgery, Sports
Traumatology, Arthroscopy.

each study. The use of a random-effects model in the

meta-analysis allows modeling of these differences, but
the overall estimate of failure risk is dependent to some
extent on these associated pathologies. The largest limitation is that only 1 comparative study was identied.
The remaining studies are all case series, introducing
multiple possible biases into the results if the 2 patient
groups were directly compared because of many potential differences in the patient groups that cannot be
controlled for. One such difference in the groups is that
the soft-tissue allograft group had a signicantly larger
number of male patients. Previous work suggests that
male patients may exhibit decreased laxity compared
Table 9. Overall International Knee Documentation
Committee Grade at Follow-Up

Author
BPTB allograft
Barrett et al.17 (2005)
Kleipool et al.21 (1998)
Melberg and Indelicato19 (1993)
Lee et al.32 (2010)
Nin et al.20 (1996)
Siebold et al.24 (2003)
Sun et al.26 (2009, KSSTA)
Sun et al.25 (2009, Arthroscopy)
Soft-tissue allograft
Lawhorn et al.27 (2012)
Lee et al.32 (2010)
Sun et al.29 (2011)
Sun et al.30 (2012)

Grade

No. of
Patients

38
36
93
60
60
164
34
80

19
17
50
25
30
48
12
30

14
13
36
28
21
90
19
45

5
5
5
6
8
26
2
4

0
1
2
1
1
0
1
1

48
153
95
38

43
65
33
12

5
77
53
22

0
11
8
3

0
0
1
1

BPTB, boneepatellar tendonebone; KSSTA, Knee Surgery, Sports

Traumatology, Arthroscopy.

Author
BPTB allograft
Bach et al.16 (2005)
Barrett et al.17 (2005)
Barrett et al.18 (2010)
Kleipool et al.21 (1998)
Peterson et al.23 (2001)
Sun et al.26 (2009, KSSTA)
Sun et al.25 (2009, Arthroscopy)
Soft-tissue allograft
Snow et al.28 (2010)
Sun et al.29 (2011)
Sun et al.30 (2012)

Lysholm
Score

Tegner
Score

82  17
91
83
94
90
91  8
91  6

6
4.1
5
5
5.4
7.5
7.6

88
90  8
90  7

6.5
7.6
7.3

NOTE. Data are presented as mean or mean SD.

BPTB, boneepatellar tendonebone; KSSTA, Knee Surgery, Sports
Traumatology, Arthroscopy.

with female patients after ACL reconstruction.36 The

identication of only 1 comparative study in the literature on this subject should serve as a call for further
comparative studies in this area.

Conclusions
One comparative study showed no difference in results after ACL reconstruction with nonirradiated BPTB
and soft-tissue allografts. Inclusion of case series in the
analysis showed qualitatively similar outcomes with the
2 graft types.

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