Editorial Commentary: High Failure Rate of All-Inside Hamstring Anterior Cruciate Ligament Reconstruction at Long-Term Follow-Up: It's the Graft Not the Construct, but the Future Keeps Complicating the Past.

Abstract

Recent reports of high failure rates after all-inside hamstring autograft anterior cruciate ligament reconstruction have renewed an old debate: is the problem the graft, the construct, or both? Interpretation is difficult because hamstring anterior cruciate ligament reconstruction has evolved alongside changes in graft configuration, socket drilling, and adjustable-loop cortical fixation. Potential contributors include graft elongation, unequal strand loading, adjustable-loop lengthening, and the longer working length of cortical fixation. Yet higher revision rates with hamstring autografts were identified before widespread adoption of the modern all-inside technique, suggesting that fixation alone does not explain the signal. Meanwhile, all-inside techniques have increasingly been paired with quadriceps tendon autograft without the same apparent failure concern. The literature remains messy, but the simplest explanation may still be the correct one: hamstring autograft itself appears less forgiving in higher-risk patients. For those patients, quadriceps or patellar tendon autograft remains the more reliable choice.