Single-Bundle Autografts Outperform Single-Bundle Achilles Allograft in Posterior Cruciate Ligament Reconstruction in Terms of Posterior Tibial Translation and Clinical Outcomes, but No Differences Exist Between Double-Bundle Grafts: A Network Meta-analysis

Background: The optimal graft choice for posterior cruciate ligament reconstruction (PCLR) remains controversial. Purpose: To evaluate and compare the biomechanical and clinical outcomes, as well as the complication and failure rates, associated with the use of Achilles allografts; hamstring tendon (HST), quadriceps tendon (QT), and bone–patellar tendon–bone (BTB) autografts; and hybrid (HY) grafts in PCLR. Study Design: Network meta-analysis; Level of evidence, 4. Methods: A comprehensive literature review was conducted to evaluate the use of various graft types in isolation for PCLR. Outcomes assessed included posterior tibial translation (PTT) at 90°, side-to-side PTT differences, Lysholm and Tegner scores, complication rates, and failure rates. Separate analyses compared single-bundle (SB) and double-bundle (DB) techniques within the Achilles, HST, and HY grafts, including different combinations for DB reconstruction. Results: A total of 53 studies involving 1861 patients met the inclusion criteria. Graft distribution was as follows: SB Achilles allograft (n = 328), DB Achilles allograft (n = 234), SB HST autograft (n = 646), DB HST autograft (n = 153), SB BTB autograft (n = 111), SB QT autograft (n = 122), and HY grafts (n = 267). Among SB grafts, SB HST exhibited the lowest PTT and highest Lysholm scores, whereas SB Achilles had the highest PTT and lowest clinical scores (P <.001). No significant differences were found between SB autografts (P =.08) or among the DB Achilles, HST, and HY grafts (P =.72). No significant difference in failure rates was observed between the DB graft groups (P =.16). Logistic regression demonstrated that relative to SB BTB, SB Achilles had the highest odds of failure (7.92), followed by SB HST (2.89) and SB QT (1.72). Combined multiligament reconstructions exhibited less PTT than isolated PCLR. Conclusion: SB autografts outperformed SB Achilles allograft in terms of PTT, and SB BTB had the lowest failure rates, while SB HST had the highest Lysholm scores. DB PCLR demonstrated superior biomechanical outcomes compared with SB reconstruction, regardless of the type of grafts used. All graft groups demonstrated a clinically significant improvement, exceeding the previously established minimal clinically important difference in the Lysholm and Tegner scores.