Quadriceps Tendon Versus Bone-Patellar Tendon-Bone Autograft for ACL Reconstruction in Athletes: A Systematic Review and Meta-Analysis

Background Quadriceps tendon (QT) and bone–patellar tendon–bone (BPTB) autografts are common options for anterior cruciate ligament reconstruction (ACLR). While outcomes in mixed populations are generally comparable, few reviews have specifically examined competitive athletes, who face higher functional demands and reinjury risk. Hypothesis/Purpose We hypothesized that clinical outcomes would differ between QT and BPTB autografts in athletes undergoing ACLR. The purpose was to compare graft failure, return to sport, and functional outcomes between these graft choices. Study Design Systematic review and meta-analysis. Methods A systematic search of PubMed, EMBASE, Web of Science, and Cochrane Library was performed through March 2025. Eligible studies included randomized controlled trials or cohort studies of competitive athletes undergoing primary ACLR with QT or BPTB autografts, reporting graft failure, return to sport, Lysholm score, or IKDC score. Studies involving pediatric patients, multiligament injuries, non-athletic populations, or other grafts were excluded. Data were pooled using random-effects meta-analysis, and certainty of evidence was assessed. Results Three studies comprising 165 athletes met inclusion criteria. Pooled analysis showed no significant difference in graft failure between QT and BPTB (OR 3.69; 95% CI, 0.60–22.59; p = 0.16; I² = 0%). Return to sport rates were similar (OR 0.90; 95% CI, 0.37–2.20; p = 0.81). Functional outcomes were also comparable: Lysholm score (MD –0.62; 95% CI, –3.49 to 2.24; p = 0.67) and IKDC score (MD –1.63; 95% CI, –4.33 to 1.08; p = 0.24). None of the included studies reported outcomes for QT soft-tissue versus bone-block subtypes, preventing subgroup analysis. Certainty of evidence was rated low due to risk of bias and imprecision. Conclusion QT and BPTB autografts demonstrate comparable rates of graft failure, return to sport, and functional scores in athletes undergoing ACLR. QT may be considered a viable alternative to BPTB in high-demand populations. Clinical Relevance Given comparable outcomes, QT autografts represent a reasonable option for athletes, particularly when minimizing anterior knee morbidity associated with BPTB graft harvest is desirable.