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.