Six randomized controlled trials including 495 patients who underwent primary anterior cruciate ligament reconstruction (ACLR) were included in this systematic review and meta-analysis comparing bone-patellar tendon-bone (BTB) autografts vs. hamstring tendon (HT) autografts. Pooled outcomes of interest included graft rupture and revision rates, contralateral ACL rupture, functional scores (Lysholm and Tegner), postoperative knee laxity, extension deficits, and osteoarthritis (OA) progression. Results showed no significant differences between BTB and HT groups for graft rupture, Lysholm and Tegner scores, knee laxity, or OA progression. However, knees undergoing ACLR, regardless of graft type, had significantly greater OA progression than contralateral knees. These findings suggest BTB and HT autografts have comparable long-term outcomes, and the choice of graft may not significantly affect long-term functional performance or OA development.