Non-hamstring ACL grafts were linked to better patient-reported outcomes, with or without an MCL injury

Design

Prospective multicentre registry cohort with propensity-score weighting (level III)

Population

489 primary ACL reconstructions, French Arthroscopy Society, 2020–2022

Primary outcome

IKDC subjective score

Effect

Non-hamstring graft β +7.89 (3.45–12.33); graft × operative MCL interaction β −7.02 (−15.26 to 1.22)

Surgeons worry that harvesting the hamstrings weakens a dynamic medial stabiliser in a knee whose MCL is also injured. This prospective French Arthroscopy Society registry examined 489 primary ACL reconstructions (2020 to 2022), grouped by medial status — isolated ACL, ACL plus MCL treated non-operatively, and ACL plus MCL treated operatively — and by graft type, using propensity-score weighting.

Non-hamstring grafts (patellar or quadriceps tendon) were associated with IKDC scores 7.89 points higher (95% CI 3.45 to 12.33), and with higher return-to-sport readiness (ACL-RSI, +6.15) and subjective knee value (+8.87); Tegner activity level did not differ. Isolated ACL injuries scored 10.41 points higher than combined injuries treated non-operatively. The graft-by-MCL interaction was not significant (operative MCL β −7.02, −15.26 to 1.22).

For practice, graft choice in a combined injury does not need to be driven by fear of the hamstring harvest; the registry suggests non-hamstring grafts do at least as well, and possibly better, across medial injury patterns. The interaction test was underpowered, and a registry cannot remove all selection bias in who got which graft.

• Consider a patellar or quadriceps tendon graft in ACL reconstruction, including when the MCL is also injured.
• Expect lower scores in combined ACL-MCL injuries than in isolated ACL tears and counsel accordingly.
• Examine and grade the MCL carefully before surgery; its status predicts outcome independent of graft.
• Discuss donor-site trade-offs: anterior knee pain with patellar tendon, and harvest-site strength loss with hamstring.
• Record graft type and MCL management in your own registry so outcomes can be audited.

Why it matters

It weakens the argument that a medial injury should steer graft choice, and adds to the case for non-hamstring grafts generally.

Don't overread it

A registry with 32% incomplete data and a non-significant but imprecise interaction; it cannot exclude that MCL status matters somewhat.

The statistics, in plain English

An 8-point IKDC difference is around the threshold patients notice. The interaction estimate (−7.02, CI −15.26 to 1.22) is not statistically significant but is wide, meaning the study could have missed a real difference in combined injuries treated operatively.

Read the rest in the app

You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.

Get Daily Doctor — free

Scan to keep reading on your phone. No account needed to start.