Sunday, October 8, 2023

Front Knee Pain After ACL Surgery?

ACL marked 20mm from each end by Dr Nuelle
While looking for a topic to write this week, I came across a research paper by Rahardja et al (2023) comparing knee pain and difficulty with kneeling between the bone-patella tendon bone (BTB) and hamstring graft after anterior cruciate ligament (ACL) reconstruction. 

I subsequently found a Twitter thread concerning the article where an orthopaedic surgeon says he "don't believe" what the paper says (see picture below).

Compared to now, there were more patients whose surgeons used the BTB graft when they tore their ACL's when I started work as a physiotherapist in the late 1990's. The hamstring autograft (not cadaver graft) is most commonly used now. 

One of the main reasons patients are told not to use a BTB graft  is because it (supposedly) causes anterior (or front) knee pain. 

A total of 10,999 patients who had ACL reconstructions were analyzed at 2-year follow-up. 9.3 percent (420 cases out of 4492 reported consequential knee pain (CKP) while 12 percent (537/4471) reported severe kneeling difficulty (SKP). For those into research, the Knee and Osteosrthritis Outcome Score (KOOS) was used to identify patients reporting CKP, defined as a KOOS Pain subscore of ≤ 72 points. 

The authors wrote that the most important predictor of CKP at 2-year follow-up was having significant pain before surgery while the most important predictor of SKP was the use of a BTB versus hamstring graft.

I do not agree with the authors' observation. I have treated many patients who had ACL reconstructions in the past 24 years. In the first few weeks after the ACL reconstruction, patients who choose either graft do have a little anterior knee pain presumably from the operation itself. After 6 weeks, anterior knee pain is very rare especially for those with the BTB graft. Very occasionally if they kneel onto the BTB graft site, they may have some kneeling pain which goes away quickly once they change position.

In fact, an orthopaedic surgeon commented that his few "non BTB" (i.e. hamstring graft) patients tend to have more anterior knee pain than his BTB graft patients (see picture below).

Moreover if you have read my earlier post, Spindler et al (2020) suggests that the HS graft is 2.1 times more likely to tear again compared to the BTB graft. Surely this is supporting evidence that the BTB graft is the 'better' and 'stronger' graft? 

There should be no reason to use "anterior knee pain" as an 'excuse' to use other graft choices rather than the BTB graft. 

Choosing your graft after tearing your ACL will definitely be influenced by discussions with your doctor, surgeon and physiotherapist. If you do not want to use your own BTB and hamstring graft, you can also use an allograft (cadaver) now. 

Please keep this information in mind if you were to tear your ACL. Come talk to us if you have any questions.


Rahardja R, Love H, Clatworthy MG et al (2023). Comparison Of Knee Pain And Difficulty With Kneeling Between Patella Tendon And Hamstring Tendon Autografts After Anterior Cruciate Ligament Reconstruction: A Study From the New Zealand ACL Registry. AJSM. DOI: 10.1177/03635465231198063

Spindler KP, Huston LJ, Zajichek A et al (2020). Anterior Cruciate Ligament Reconstruction In High School And College-age Athletes: Does Autograft Choice Influence Anterior Cruciate Ligament Revision Rates? 48(2): 298-309. DOI: 10.1177/0363546519892991.

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