PurposeThis study aims to perform a network meta‐analysis of hamstring graft preparation techniques to enhance anterior cruciate ligament (ACL) reconstruction guidelines and inform clinical decision‐making in patients with primary ACL rupture.MethodsA review of the literature, from 1 January 1990, to 31 August 2023, was conducted following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines, focusing on the clinical outcomes of various hamstring graft preparation techniques. Forty‐six studies (over 4800 knees) were analysed. Eight graft compositions: doubled hamstring (ST/G)—1978 grafts, doubled hamstring with augmentation (ST/G+A)—586 grafts, tripled semitendinosus (3ST)—124 grafts, quadrupled semitendinosus (4ST)—1273 grafts, five‐strand tripled semitendinosus + doubled gracilis (3ST/2GR—839 grafts, six‐strand tripled semitendinosus + tripled gracilis (3ST/3GR)—335 grafts, seven‐strand quadrupled semitendinosus + tripled gracilis (4ST/3GR)—11 grafts and ≥eight strands—24 grafts were compared, considering graft sizes, laxity, muscle strength, range‐of‐motion, patient‐reported outcome measures (PROMs), return to sport (RTS) and adverse events.ResultsThe 4ST grafts fared better than the ST/G grafts in the International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS) Sport, KOOS Q and RTS (mean difference [MD], −1.69; p = 0.0159; MD, −1.55; p = 0.0325; MD, −1.93; p = 0.001; odds ratio: 3.13; p < 0.0001). The IKDC differed significantly between the 4ST and ST/G+A groups (MD, 1.88; p = 0.046). The ST/G+A resulted in the lowest knee laxity, surpassing the ST/G, 3ST and 4ST. The ST/G had the smallest diameter (ST/G vs. ST/G+A: MD, 1.26; 95% confidence interval [CI]: 0.67–1.86, p < 0.0001). Reduced failure rates were noted with the 3ST/2GR (3ST/2GR vs. ST/G: MD, 6.93; p = 0.009) and 3ST/3GR (3ST/3GR vs. ST/G: MD, 53.64; p = 0.006).ConclusionThe ideal hamstring graft for ACLR should be individualized. A 4ST graft is likely to yield good PROMs. For high stability and rapid RTS, adding augmentation to the graft is advisable. The ST/G is the thinnest graft possible.Level of EvidenceNetwork meta‐analysis of level I–III studies.
