Quadriceps Tendon Autograft Versus Bone–Patellar Tendon–Bone and Hamstring Tendon Autografts for Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Abstract

Background: The best type of autograft for anterior cruciate ligament (ACL) reconstruction remains debatable. Hypothesis: Compared with bone–patellar tendon–bone (BPTB) and hamstring tendon (HT) autografts, the quadriceps tendon (QT) autograft has comparable graft survival as well as clinical function and pain outcomes. Study Design: Meta-analysis; Level of evidence, 4. Methods: A systematic literature search was conducted in PubMed, Embase, Scopus, and the Cochrane Library to July 2020. Randomized controlled trials (RCTs) and observational studies reporting comparisons of QT versus BPTB or HT autografts for ACL reconstruction were included. All analyses were stratified according to study design: RCTs or observational studies. Results: A total of 24 studies were included: 7 RCTs and 17 observational studies. The 7 RCTs included 388 patients, and the 17 observational studies included 19,196 patients. No significant differences in graft failure ( P = .36), the International Knee Documentation Committee (IKDC) subjective score ( P = .39), or the side-to-side difference in stability ( P = .60) were noted between QT and BPTB autografts. However, a significant reduction in donor site morbidity was noted in the QT group compared with the BPTB group (risk ratio [RR], 0.17 [95% CI, 0.09-0.33]; P < .001). No significant differences in graft failure ( P = .57), the IKDC subjective score ( P = .25), or the side-to-side stability difference ( P = .98) were noted between QT and HT autografts. However, the QT autograft was associated with a significantly lower rate of donor site morbidity than the HT autograft (RR, 0.60 [95% CI, 0.39-0.93]; P = .02). A similar graft failure rate between the QT and control groups was observed after both early and late full weightbearing, after early and late full range of motion, and after using the QT autograft with a bone plug and all soft tissue QT grafts. However, a significantly lower rate of donor site morbidity was observed in the QT group compared with the control group after both early and late full weightbearing, after early and late full range of motion, and after using the QT autograft with a bone plug and all soft tissue QT grafts. No difference in effect estimates was seen between RCTs and observational studies. Conclusion: The QT autograft had comparable graft survival, functional outcomes, and stability outcomes compared with BPTB and HT autografts. However, donor site morbidity was significantly worse with the QT autograft than with BPTB and HT autografts.

Clinical Outcomes After Combined ACL and Anterolateral Ligament Reconstruction Versus Isolated ACL Reconstruction With Bone–Patellar Tendon–Bone Grafts: A Matched-Pair Analysis of 2018 Patients From the SANTI Study Group

“…29,41 A recent meta-analysis comparing BPTB, HT, and QT grafts reported a lack of important differences between groups with respect to knee stability, graft rupture rates, and the International Knee Documentation Committee subjective score, but did identify significantly lower rates of donor-site morbidity with QT grafts than with either of the other choices. 9 It is seemingly the case that the trend away from BPTB grafts has been driven by concerns about donor-site morbidity (especially anterior knee pain) 7,16 and higher rates of extension deficits. 1,13,37,46 However, it is clear that all graft choices have pros and cons, and the optimum graft choice remains a controversial topic.…”

Surgical techniques in the management of pediatric anterior cruciate ligament tears: Current concepts

“…Disadvantages include possible higher re-rupture rates, a reduction in sprint speeds, variations in graft size and inferior graft host integration times when compared to BTB. 51 , 53 Furthermore, recent debate has highlighted the importance of gender-specific graft choice which may have potential implication for rehabilitation. Young females are more likely to have a high quadriceps to hamstring activation imbalance which may have implications for reinjury and revision rates.…”

Current trends in graft choice for primary anterior cruciate ligament reconstruction – part II: In‐vivo kinematics, patient reported outcomes, re‐rupture rates, strength recovery, return to sports and complications

“…Additionally, a multicenter RCT with 16-year follow-up revealed no statistical differences in PROs between both graft options [ 10 ]. These RCTs have been reinforced by several large registry studies [ 35 , 102 , 107 , 113 ], systematic reviews, and meta-analyses [ 21 , 90 , 133 ] showing no difference in PROs between patients treated with BPTB or HT. Similarly, no significant differences have been reported among other mid- to long-term studies using the transtibial approach [ 14 , 34 , 46 , 112 , 130 ].…”

“…In highly active patients (Tegner-activity-level ≥ 7), the re-rupture rate increased to 37.5% in the HT group while remaining constant in the QT cohort (22.2%). Results of recent systematic reviews and meta-analyses are inconclusive, reporting either higher [ 52 , 94 ] or equal [ 21 , 91 , 120 ] re-rupture and revision surgery rates for HT versus QT.…”