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Comparative assessment of graft maturity after anterior cruciate ligament reconstruction using different graft types: a systematic review

Yingchang Pang,Sibo Xu,Gengxian Xiang,Kaiqi Zhang,Tiezheng Sun

Published 2026 in Journal of Orthopaedic Surgery and Research

ABSTRACT

The selection of graft remains a subject of ongoing debate in anterior cruciate ligament (ACL) reconstruction, with distinct maturation processes having been observed among different graft types. A thorough understanding of these differences in graft maturation is crucial for optimizing rehabilitation protocols and ensuring a safe return to sports. This study aimed to systematically review the differences in graft maturation among different graft types following ACL reconstruction. A comprehensive literature search was conducted in PubMed, Embase, and the Cochrane Library in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included only if they compared intra-articular ACL graft maturity across different graft types. Twenty-one studies met the inclusion criteria. Graft maturity was assessed using magnetic resonance imaging (MRI) in 15 studies, second-look arthroscopy in 4 studies, and histological biopsy in 1 study; one additional study utilized both MRI and second-look arthroscopy. Hamstring tendon (HT) and bone-patellar tendon-bone (BPTB) autografts showed similar maturity, as assessed by MRI signal intensity (SI) and histological findings, after ACL reconstruction. However, results from second-look arthroscopy were inconclusive. HT autografts exhibited MRI SI comparable to soft-tissue allografts within the first postoperative year, but demonstrated superior maturity and graft appearances at approximately 2 years postoperatively. Quadriceps tendon (QT) autografts, both with and without a patellar bone block, revealed lower MRI SI compared to HT autografts, suggesting better graft maturity. HT autografts with preserved tibial insertion maintained relatively lower SI during the early maturation phase (6 and 12 months) than free HT autografts, though no significant differences were observed at later stages (24 and 60 months). MRI, second-look arthroscopy, and histological biopsy analysis indicated distinct graft maturation levels following ACL reconstruction. No conclusive evidence established whether HT or BPTB autografts are superior in terms of graft maturity. Compared to free HT autografts and soft-tissue allografts, QT autografts and HT autografts with preserved tibial insertion may mature earlier, which may allow for consideration of an earlier return to sports in clinical decision-making. These grafts may therefore represent viable alternatives to HT and BPTB grafts, particularly in young and active patients. III, systematic review of level Ⅰ-Ⅲ investigation.

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