Fourfold higher graft failure risk with isolated BPTB versus hamstring ACL reconstruction with ALL in patients under 25 years: A prespecified subgroup analysis of a randomized controlled trial

Abstract Purpose To compare 5‐year graft failure rates between isolated bone–patellar tendon–bone anterior cruciate ligament reconstruction (BPTB‐ACLR) and hamstring tendon (HT)‐ACLR combined with anterolateral ligament reconstruction (ALLR) in patients younger than 25 years. Methods A prespecified subgroup analysis was performed on patients younger than 25 years enroled in a prospective comparative study. Patients underwent either isolated ACLR using a BPTB‐ACLR or hamstring ACLR combined with ALLR (HT‐ACLR + ALLR). The primary outcome was graft failure at 5 years. Secondary outcomes included patient‐reported outcome measures (Knee injury and Osteoarthritis Outcome Score [KOOS], International Knee Documentation Committee [IKDC], Lysholm and Tegner scores). Survival analysis was performed using Kaplan–Meier estimates and log‐rank testing. Multivariate logistic regression and Cox proportional hazards models were used to identify independent risk factors for graft failure. Results The analysis included 281 patients younger than 25 years, with 134 undergoing isolated BPTB‐ACLR and 147 undergoing HT‐ACLR + ALLR. At 5 years, graft failure occurred in 22 patients (16.4%) in the isolated BPTB‐ACLR group and in 7 patients (4.8%) in the HT‐ACLR + ALLR group ( p = 0.0013). Kaplan–Meier analysis demonstrated significantly improved graft survival in the HT‐ACLR + ALLR group (log‐rank p = 0.0008). On multivariate analysis, isolated BPTB‐ACLR was independently associated with a higher risk of graft failure compared with HT‐ACLR + ALLR (odds ratio 4.2; 95% confidence interval [CI] 1.8–11.3; p = 0.0007; hazard ratio 4.2; 95% CI 1.9–10.7; p = 0.0002). Clinical outcome scores were comparable between groups at follow‐up across all patient‐reported measures. Conclusion This secondary analysis of a RCT with 5‐year follow‐up showed that, in patients younger than 25 years, HT‐ACLR combined with ALLR was associated with a significantly lower risk of graft failure compared with isolated BPTB‐ACLR, whereas patient‐reported clinical outcomes were comparable between groups. Level of Evidence Level I, randomized controlled trial.