Quadriceps, hamstring and patella tendon autografts for primary anterior cruciate ligament reconstruction demonstrate similar clinical outcomes, including graft failure, joint laxity and complications: A systematic review with meta-analysis of randomised controlled trials

Purpose Graft failure following anterior cruciate ligament reconstruction (ACLR) remains a significant challenge, driving discussion for optimal graft choice. Traditionally, hamstring tendon (HT) and bone-patella tendon-bone (BPTB) autografts have been favoured for ACLR. Recently, quadriceps tendon (QT) usage has increased. This systematic review with meta-analysis aims to investigate the available evidence for QT compared to HT and BPTB autografts in terms of graft failure, clinical outcomes, functional outcomes and patient-reported outcome measures (PROMs). Methods Five databases (PubMed, Cochrane, Embase, SPORTDiscus and CINAHL) were searched to identify randomised controlled trials comparing QT versus HT or BPTB autografts. Outcomes included graft failure, donor site morbidity, complications, reoperations, clinical measures, functional outcomes, and PROMs. Risk of bias was assessed using the Cochrane risk-of-bias tool (RoB2). Meta-analysis using a random effects model was conducted to determine the pooled risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CIs), and certainty of evidence was evaluated via the GRADE approach. Results Twelve RCTs consisting of 636 patients were included. Meta-analysis revealed no differences in graft failure rates (RR = 1.00; 95% CI = 0.97-1.04; p = 0.83; I-2 = 0%; high certainty). QT autografts demonstrated lower donor site morbidity when compared to HT and BPTB autografts (RR = 1.45; 95% CI = 1.24-1.70; p < 0.001; I-2 = 0%; high certainty). No differences were observed in joint laxity or PROM scores at 12 and 24 months, except for Knee injury and Osteoarthritis Outcome Score favouring HT and BPTB at 12 months (RR = 2.49; 95% CI = -4.69 to -0.28; p = 0.03; I-2 = 0%; very low certainty). Conclusion QT autografts have similar outcomes for graft failure, laxity and PROMs compared to HT and BPTB; however, QT autografts may have lower donor site morbidity. While each graft type is associated with specific complications and post-operative strength deficits, all three remain viable options for ACLR.