IntroductionA lot of research addresses superiority of the two commonly used autografts bone-patellar tendon-bone (BPTB) and hamstring tendon for anterior cruciate ligament (ACL) reconstruction, without getting to consensus. While there are numerous studies and reviews on short- to mid-term follow-up, not much literature is available on long-term follow-up. As patients suffering ACL injuries are often of young age and high athletic activity, it is crucial to have the best evidence possible for graft choice to minimize consequences, like osteoarthritis later on.Materials and methodsA search of the online databases, PubMed and Embase, was carried out last on 31st March 2022 for studies comparing BPTB and hamstring tendon (HT) autografts for ACL reconstruction in human patients with a minimum follow-up of 10 years. The methodological quality of each study has been evaluated using the modified Coleman Methodology Score. Results on the three variables patient-oriented outcomes, clinical testing and measurements and radiographic outcomes were gathered and are presented in this review.ResultsOf 1299 records found, nine studies with a total of 1833 patients were identified and included in this systematic review. The methodological quality of the studies ranged from a Coleman Score of 63–88. Many studies reported no or only few statistically significant differences. Significant results in favour of BPTB were found for activity levels and for instrumented laxity testing with the KT-1000 arthrometer. Better outcomes for HT were found in IKDC-SKF, the KOOS, donor site morbidity, pivot shift test, radiographic osteoarthritis (IKDC C or D) and contralateral ACL rupture. No studies presented significant differences in terms of Lysholm Score or Tegner Activity Score, Lachman test, single-legged hop test, deficits in range of motion, osteoarthritis using the Kellgren and Lawrence classification or graft rupture.ConclusionWe cannot recommend one graft to be superior, since both grafts show disadvantages in the long-term follow-up. Considering the limitation of our systematic review of no quantitative analysis, we cannot draw further conclusions from the many insignificant results presented by individual studies.Level of evidence: IV.