Volume 13, Issue 3 (Summer 2026)
JROS 2026, 13(3): 87-98 |
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Jabalameli M, Bagherifard A, Askari A, Yahyazadeh H, Azimi A, Arjmand K, et al . Anterior Cruciate Ligament Graft Choice in Patients With Generalized Joint Hypermobility, Generalized Joint Laxity, or Knee Hyperextension: A Narrative Review. JROS 2026; 13 (3) :87-98
URL: http://jros.iums.ac.ir/article-1-2326-en.html
URL: http://jros.iums.ac.ir/article-1-2326-en.html
Mahmoud Jabalameli1 
, Abolfazl Bagherifard1 , Alireza Askari2 , Hooman Yahyazadeh3 , Amir Azimi4 , Kamal Arjmand5 , Bushra Zareie5 , Behnam Sour2
, Abolfazl Bagherifard1 , Alireza Askari2 , Hooman Yahyazadeh3 , Amir Azimi4 , Kamal Arjmand5 , Bushra Zareie5 , Behnam Sour2
1- Bone and Joint Reconstruction Research Center, Shafa Yahyaeian Hospital, Iran University of Medical Sciences, Tehran, Iran.
2- Department of Orthopedics, Bone and Joint Reconstruction Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran. & Department of Orthopedic Surgery, Bone and Joint Reconstruction Research Center, Shafa Yahyaeian Hospital, Tehran, Iran.
3- Department of Orthopedic Surgery, Bone and Joint Reconstruction Research Center, Shafa Yahyaeian Hospital, Tehran, Iran. & Department of Orthopedic Surgery, Farhikhtegan Hospital, TeMS.C., Islamic Azad University, Tehran, Iran.
4- Bone and Joint Reconstruction Research Center, Department of Orthopedics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
5- Department of Orthopedics, Bone and Joint Reconstruction Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
2- Department of Orthopedics, Bone and Joint Reconstruction Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran. & Department of Orthopedic Surgery, Bone and Joint Reconstruction Research Center, Shafa Yahyaeian Hospital, Tehran, Iran.
3- Department of Orthopedic Surgery, Bone and Joint Reconstruction Research Center, Shafa Yahyaeian Hospital, Tehran, Iran. & Department of Orthopedic Surgery, Farhikhtegan Hospital, TeMS.C., Islamic Azad University, Tehran, Iran.
4- Bone and Joint Reconstruction Research Center, Department of Orthopedics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
5- Department of Orthopedics, Bone and Joint Reconstruction Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
Abstract: (16 Views)
Background: Generalized joint hypermobility (GJH), generalized joint laxity (GJL), and knee hyperextension may increase anterior and rotational loads after anterior cruciate ligament (ACL) reconstruction. In these patients, graft choice may influence postoperative stability and failure risk.
Objectives: This study aimed to review the clinical and mechanistic evidence on graft choice for ACL reconstruction in patients with GJH, GJL, or knee hyperextension.
Methods: This narrative review used a structured, evidence-based, graft-stratified approach to clinical studies. Outcomes included graft rupture, second ACL injury, measured anterior laxity, pivot shift, and patient-reported knee scores. Mechanistic evidence on graft stiffness, fixation, elongation, and healing was used to interpret the clinical findings.
Results: Available evidence is limited and mostly observational. Across graft-stratified studies, bone-patellar tendon-bone (BPTB) autograft was associated with lower measured anterior translation than hamstring autograft in laxity-pattern knees. Limited pooled data also favored BPTB for anterior translation and Lysholm score at approximately 24 months. Registry evidence after return to sports suggested higher second ACL rupture and graft rupture rates after hamstring autograft than after BPTB autograft. Quadriceps tendon autograft with a bone block appears promising, especially in knee hyperextension, but direct evidence in systemic hypermobility remains limited.
Conclusion: In patients with GJH, GJL, or marked knee hyperextension, ACL graft choice should be considered a stability-focused decision. Current evidence most consistently supports BPTB autograft when objective stability is prioritized. Quadriceps tendon autograft with a bone block is promising but requires further study.
Objectives: This study aimed to review the clinical and mechanistic evidence on graft choice for ACL reconstruction in patients with GJH, GJL, or knee hyperextension.
Methods: This narrative review used a structured, evidence-based, graft-stratified approach to clinical studies. Outcomes included graft rupture, second ACL injury, measured anterior laxity, pivot shift, and patient-reported knee scores. Mechanistic evidence on graft stiffness, fixation, elongation, and healing was used to interpret the clinical findings.
Results: Available evidence is limited and mostly observational. Across graft-stratified studies, bone-patellar tendon-bone (BPTB) autograft was associated with lower measured anterior translation than hamstring autograft in laxity-pattern knees. Limited pooled data also favored BPTB for anterior translation and Lysholm score at approximately 24 months. Registry evidence after return to sports suggested higher second ACL rupture and graft rupture rates after hamstring autograft than after BPTB autograft. Quadriceps tendon autograft with a bone block appears promising, especially in knee hyperextension, but direct evidence in systemic hypermobility remains limited.
Conclusion: In patients with GJH, GJL, or marked knee hyperextension, ACL graft choice should be considered a stability-focused decision. Current evidence most consistently supports BPTB autograft when objective stability is prioritized. Quadriceps tendon autograft with a bone block is promising but requires further study.
Keywords: Anterior cruciate ligament (ACL) reconstruction, Graft choice, Generalized joint hypermobility (GJH), Generalized joint laxity (GJL), Knee hyperextension, Bone-patellar tendon-bone (BPTB), Hamstring tendon, Quadriceps tendon
Type of Study: Review Paper |
Subject:
Knee surgery
Received: 2026/02/1 | Accepted: 2026/03/12 | Published: 2026/08/10
Received: 2026/02/1 | Accepted: 2026/03/12 | Published: 2026/08/10
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