Knee Surg Sports Traumatol Arthrosc. 2026 Jun 24. doi: 10.1002/ksa.70499. Online ahead of print.
ABSTRACT
PURPOSE: To compare clinical and functional outcomes after primary anterior cruciate ligament reconstruction (ACLR) using quadriceps tendon (QT) autografts versus bone-patellar tendon-bone (BPTB) and, separately, QT versus hamstring tendon (HT) autografts, to inform evidence-based graft selection.
METHODS: We performed a Cochrane-guided systematic review and meta-analysis. Searches of PubMed, Scopus, Cochrane Library, SPORTDiscus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science and major trial registries through November 2025 identified randomized controlled trials (RCTs) comparing QT with HT or BPTB in adults undergoing primary ACLR. Random-effects models (REML) were used to pool mean differences/standardized mean differences and risk ratios. Heterogeneity was quantified using I2 and Q statistics. Sensitivity analyses (leave-one-out) and the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach were applied. When pooling was infeasible, a structured narrative synthesis was provided.
RESULTS: Fifteen RCTs (2014-2025) were included. Objective anterior stability (KT-1000) showed no significant difference between QT and HT at 12 or 24 months and no significant difference between QT and BPTB at 12 months. Patient-reported outcomes (International Knee Documentation Committee, Lysholm, Knee Injury and Osteoarthritis Outcome Score [KOOS], Tegner) were largely equivalent at 12-24 months. After resolving inconsistencies due to non-exchangeable constructs/comparators, a small 12-month KOOS signal favoured QT, while 24-month effects remained null. Graft failure rates were comparable for QT versus HT and QT versus BPTB. Donor-site morbidity was substantially lower with QT versus BPTB; QT versus HT showed no significant difference. Pivot-shift favoured QT, but not significantly; postoperative stiffness did not differ. Overall certainty was mostly moderate (downgrades for imprecision and occasional indirectness); donor-site morbidity versus BPTB reached high certainty.
CONCLUSION: Across randomized evidence up to 24 months, QT provides stability and patient-reported outcomes comparable to HT and BPTB, with clearly lower donor-site morbidity compared to BPTB and no excess failure compared to HT. QT is an evidence-supported alternative for primary ACLR; longer, adequately powered, construct-specific RCTs are needed for guideline-level certainty.
LEVEL OF EVIDENCE: Level I, systematic review of Level I randomized controlled studies.
PMID:42340609 | DOI:10.1002/ksa.70499
