Quadriceps versus hamstring and patellar tendon autografts for ACL reconstruction: A systematic review and meta-analysis

Aim: <br/>To compare quadriceps tendon (QT) autografts with hamstring tendon (HT) and bone patellar tendon-bone (BPTB) autografts for primary anterior cruciate ligament reconstruction. <br/><br/>Design: <br/>Systematic review and meta-analysis. <br/><br/>Methods: <br/>Databases were searched for RCTs comparing QT with HT, and BPTB autografts in primary anterior cruciate ligament reconstruction (ACLR). Study selection followed the PRISMA guidelines, with methodological quality assessed via the Cochrane risk-of-bias tool and the GRADE for certainty of evidence. Outcomes included graft failure, donor site morbidity, complications, clinical measures, functional outcomes, and PROMs. Meta-analysis determined pooled effects on eligible outcomes. <br/><br/>Results: <br/>Twelve RCTs (636 patients) showed no differences in graft failure rates (RR, 1.00 [95% CI, 0.97 to 1.04]; p = 0.83). QT demonstrated lower donor site morbidity compared to HT and BPTB autografts (RR, 1.45 [95% CI, 1.24 to 1.70]; p &lt; 0.001). For strength outcomes, QT showed superior hamstring strength and hamstring: quadriceps ratio, while HT demonstrated greater quadriceps strength. Joint laxity and most PROMs were comparable between groups, with the exception of KOOS at 12 months, which favoured HT and BPTB autografts. <br/><br/>Conclusions: <br/>QT autografts demonstrate equivalent graft failure, laxity, and most PROMs compared to HT and BPTB autografts, while offering significantly lower donor site morbidity and better hamstring strength preservation in primary ACLR. <br/><br/>Key practice points: <br/>• All three autograft types (QT, HT, BPTB) yield comparable ACLR outcomes <br/>despite specific complications and strength differences. <br/>• Standardised reporting of graft failure and post-operative complications is <br/>needed in future research. <br/>• Patient-specific factors and rehabilitation goals should guide individualised graft selection.