Knee pain associated with bone–patellar tendon–bone autografts does not limit activity levels, sports participation or quality of life after ACL reconstruction

PURPOSE: Bone-patellar tendon-bone (BPTB) and Hamstring (HT) autografts are commonly used for anterior cruciate ligament reconstruction (ACLR). Concerns exist regarding postoperative anterior knee pain (AKP) and kneeling discomfort with BPTB grafts. However, many studies solely report the presence/absence of anterior knee pain, without assessing its clinical significance in terms of functional limitation or impact on quality of life. METHODS: This study prospectively analysed 1407 patients undergoing primary ACLR with BPTB or HT autografts. Knee pain prevalence, severity, and location were measured at 6 months, 1 year, 2 years, and 5 years postoperatively using a pain questionnaire. Patient-reported measures (Knee Injury and Osteoarthritis Outcome Score KOOS, Western Ontario and McMaster Universities Osteoarthritis Index WOMAC, International Knee Documentation Committee IKDC and Marx) and return to play (RTP) rates were also collected to evaluate knee symptoms, function and activity levels. Multivariable regression identified factors associated with knee pain at each time point. RESULTS: The mean age was 24.5 ± 7.1 years, with 74.3% male. BPTB grafts were used in 81% (n = 1145) and HT in 19% (n = 262). At 6 months, the BPTB group reported a higher prevalence of AKP (26% vs. 6%, p < 0.001). There was no difference between graft types at 1 year and 2 years postoperatively. At 5 years, the BPTB group were 1.59 times more likely to report pain, although most pain was mild and there was no significant differences in KOOS, WOMAC, IKDC, Marx scores or RTP rates. Female patients (OR 1.41, p < 0.035) and BPTB grafts (OR 1.78, p < 0.004) were associated with knee pain at 6 months. At 5 years, older age (OR 1.06, p < 0.001), BPTB grafts (OR 1.59, p < 0.027), and medial femoral condyle chondral pathology (OR 1.7, p < 0.020) increased the odds of having pain. CONCLUSION: BPTB grafts are associated with early AKP, which improves over time. AKP related to BPTB is mild and does not affect activity levels, sports participation or quality of life. Mild AKP should not deter surgeons from using BPTB autografts for ACLR, given the other advantages of this graft choice. LEVEL OF EVIDENCE: Level II, prospective study.