- Original Paper
- Open Access
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
Journal of Experimental Orthopaedics volume 10, Article number: 40 (2023)
Postoperative patient satisfaction after anterior cruciate ligament reconstruction (ACL-R) is influenced mainly by the degree of pain, the need for reoperation, and functional performance in daily activities and sports. Graft choice has shown to have an influence on postoperative outcomes after ACL-R. While patient reported outcomes measurements do not differ between graft options, evidence shows that normal knee kinematics is not fully restored after ACL-R with an increase in postoperative anterior tibial translation (ATT). Postoperative graft rupture rates seem to favor bone-patella-tendon-bone (BPTB) and quadriceps tendon (QT) autografts over HT or allografts. While return to sports rates seem comparable between different graft types, postoperative extensor strength is reduced in patients with BPTB and QT whereas flexion strength is weakened in patients with HT. Postoperative donor site morbidity is highest in BPTB but comparable between HT and QT. With all graft options having advantages and drawbacks, graft choice must be individualized and chosen in accordance with the patient.
Pain, graft survival, and functional performance during daily activity and sport all significantly affect patient satisfaction following anterior cruciate ligament (ACL) reconstruction (ACL-R). Details about anatomy, biomechanics, graft fixation and incorporation commonly used autograft and allografts are reviewed in part I of this current concept paper. The following review will further highlight in-vivo analyses, patient reported outcomes (PROs), re-rupture rates, flexion and extension strength recovery, return to sport, and complications of the quadriceps tendon (QT), bone-patella-tendon-bone (BPTB) and hamstring tendon (HT) autograft as well as allografts. Unless otherwise specified, for the purposes of uniform comparison only studies using anteromedial portal drilling technique were included, as clinical and functional outcomes may differ with more traditional techniques .
Measuring in-vivo knee kinematics during daily and athletic activities is essential to detect abnormal joint mechanics and microinstability which may not present during routine clinical testing, yet may lead to accelerated joint degeneration .
ACL-R has been shown to have a significant impact on knee kinematics, with reconstructed knees more externally rotated and less flexed than the contralateral limb in the early stance phase of the running cycle one year postoperatively [13, 44, 121, 122]. Additionally, graft length was found to be 4 – 6 mm shorter compared to the native ACL at 6 and 24 months postoperatively throughout early stance . While the clinical influence has yet to be determined, it can be hypothesized that a shorter and stiffer graft results in a more externally rotated tibia due to the oblique ACL fiber direction. This in turn may lead to an over-constrained joint in the early postoperative period . However, over time there is an apparent decrease in external tibial rotation paired with graft lengthening and an increase in anterior tibial translation (ATT), indicating a stretching and functional remodeling of the graft .
Overall, the effect of different graft types on in-vivo kinematics remains inconclusive. For HT ACL-R an increased ATT during activity was reported and linked to a reduction in hamstring force . Similarly, evidence shows that normal knee kinematics does not fully reestablish under weightbearing conditions after BPTB ACL-R even though anterior knee laxity measurements were restored during KT-1000 arthrometer testing . A comparative study of HT- and BPTB ACL-R using dynamic biplanar radiography revealed no statistically significant difference in postoperative ATT between both graft options . However, although not statistically significant, a higher ATT was measured in the HT group compared with BPTB during walking at 6 weeks. This again may be attributed to less posterior hamstring pull on the tibia in the early postoperative phase, which resolves after physical therapy and strength restoration .
Patient reported outcome measures
Postoperative patient satisfaction is undoubtedly the most important outcome when it comes to ACL-R. While there is an abundance of short-, mid- and long-term literature comparing BPTB and HT, little is known about postoperative outcomes of QT. Although BPTB autograft has long been the gold standard in ACL–R, QT is gaining in popularity, especially among patients injured in pivoting sports and in those with concomitant medial collateral ligament injuries [7, 108].
To date, only two randomized controlled trials (RCTs) have compared clinical outcomes of BPTB and QT. Randomizing 51 patients using a transtibial ACL-R technique revealed no statistically significant difference in any of the reported PROs at two years postoperative . Similar, no long-term differences were observed between quadriceps-tendon–patella bone autograft or BPTB in 60 athletes (Tegner > 6). In contrast, a multicenter, observational study reported significantly higher Lysholm scores for QT when compared to BPBT, yet similar results when compared to HT . Several cohort studies as well as recent systematic reviews and meta-analyses support the findings of these randomized trials, demonstrating no significant difference in PROs between patients treated with QT or BPTB [21, 62, 86, 91, 100].
When comparing BPTB to HT, three recent RCTs demonstrated no significant differences between subjective IKDC and Lysholm scores [53, 88, 112]. Additionally, a multicenter RCT with 16-year follow-up revealed no statistical differences in PROs between both graft options . 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].
The reported results of QT and HT are similar to those of BPTB and HT. In a recent prospective RCT, Lind et al.  compared 50 patients treated with QT to 49 patients treated with HT and found no significant differences in PROs. Similarly, no significant differences in PROs were reported in competitive football players . A registry study including 479 patients and two matched-pair analysis further revealed no significant difference between PROs following isolated QT or HT ACL-R in short- and after minimum five years [109,110,111]. Recent smaller observational studies as well as systematic reviews and metanalyses have confirmed the findings of the above-mentioned comparative studies, showing comparable PROs between patients treated with both graft options [2, 9, 21, 86, 91, 95, 99, 127].
While allografts were historically associated with inferior clinical and patient reported outcomes, recent studies using non-irradiated and non-chemically treated allografts produce comparable patient satisfaction rates and PROs to autografts [11, 24, 36, 59, 128, 135].
Graft failure rates
Graft failure is multifactorial. Risk factors include male gender , younger age [57, 58, 62, 89, 105, 109], family history [17, 137], ethnicity , lower body mass index (BMI) , increased posterior tibial slope [25, 28, 40, 131], high activity level [17, 57, 58, 109] and concomitant injuries . As many of these factors are non-modifiable, operative technique and graft choice remain easily adjustable factors influencing postoperative outcomes and re-rupture rates [31, 98, 102, 106, 107, 113, 133, 137].
When comparing graft failure rates, care must be taken with terminology, as the terms "graft rupture," “failure rates,” and "revision surgery" are often used interchangeably and interpreted inconsistently. Particularly in registry studies, “revision surgery” may be reported rather than graft ruptures, as determined by postoperative MRI or clinical examination. This may lead to underestimation of true re-rupture rates. In terms of re-rupture, BPTB has long been considered the gold standard, demonstrating decreased rates compared to HT and allograft [3, 35, 65, 74, 76,77,78,79, 124, 137]. However, RCTs and observational studies comparing BPTB and QT report similar graft rupture rates, ranging from 1.4—7.5% and 2.0—5.1%, respectively [8, 37, 45, 100]. These results have been supported in recent systematic reviews and meta-analyses showing no significant difference between both graft options [21, 91].
There is extensive evidence on ACL revision surgery rates between BPTB and HT. Out of eleven registry studies, nine reported a significant relationship between revision rate and graft choice, with patients undergoing HT ACL-R having an up to two times higher risk of revision [3, 35, 65, 74, 76,77,78,79, 124]. In contrast, four systematic reviews and meta-analyses reported no statistically significant difference in re-rupture and reoperation rates; however, a tendency toward higher re-rupture rates for HT remains [21, 41, 90, 133].
When comparing failure rates of QT to HT, high-level evidence is still lacking. Two RCTs including 99 and 51 patients respectively, found no significant difference between both graft options in the short term [47, 71]. These results are supported by other short-term observational studies in adult [2, 15, 60, 111, 127] and pediatric patients . Contrary to the above-mentioned findings, a recent registry study including 875 patients showed a 2.7 times higher probability of revision surgery when an HT (4.9%) was used compared to QT (2.8%). This difference was even more pronounced in high-level athletes (Tegner activity score ≥ 7), with revision surgery rates of 11.1% and 5.0%, respectively. In less active patients, low revision rates with minor differences were observed (QT: 3.0%, HT: 4.2%). Interestingly, patients with QT showed no difference in the rate of ipsilateral revision surgery and the number of contralateral ACL-R compared to those treated with HT. This indicates a possible superiority of the QT to lower the graft rupture risk to the level of the uninjured, contralateral leg . Similarly, a recent mid-term, matched-pair comparative study revealed no statistically significant difference between both graft options (QT: 17.8%; HT: 22.2%). 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.
There is extensive but contradicting evidence comparing graft rupture rates between allograft and autograft. Allografts are thought to have higher rupture and reoperation rates, with an up to sixfold increased risk of failure when compared to autograft, especially in young and active patients [18, 58, 63, 72, 96, 126]. Sterilization using radiation, especially with doses greater than 20 kGy, has been implicated as a likely cause due to unfavorable biomechanical effects on the tissue [66, 115].
In more recent studies comparing non-irradiated or fresh frozen allograft to autograft, these higher failure rates have not been consistently reported [11, 24, 26, 68, 135]. Notably, the literature suggests that allografts are now predominantly used in older and less active patients, two well-known factors that lower graft failure rates [26, 85, 103]. This change in indication resulted due to higher graft failure rates observed in young and active individuals with the use of allograft [27, 57, 58, 96, 129]. The Multicenter Orthopaedic Outcomes Network (MOON) registry has shown that changing the indications for allograft based on patient age and sport activity have resulted in a 68% decrease in graft failure rates. However, the odds of failure with allograft in this study remained 9.5 times higher compared to autograft. . Thus, although several systematic reviews and meta-analyses comparing autograft to non-irradiated or fresh frozen allograft have reported no significant differences in failure rates in older patients [24, 134, 136], the use of allograft in young and active individuals remains unacceptably high and is therefore not recommended in this age group [18, 50, 58, 63, 72, 126].
Regaining normal extensor and flexor muscle strength after ACL-R, measured by a limb symmetry index (LSI) of > 90%, is a key focus of rehabilitation. The goal is to ensure safe return to sport and work, as inadequate strength has been associated with poorer function, altered biomechanics, and an increased risk of further knee injury [38, 116, 138]. Isokinetic strength testing is considered the “gold-standard” for postoperative strength testing, however varied testing protocols limit the comparability of studies . When comparing different graft options, recent systematic reviews and meta-analyses demonstrate different outcomes .
Comparing QT- to BPTB and HT, significantly increased isometric quadriceps weakness at 5–8 months postoperatively with QT, but no significant difference between groups at 9 to 15 months has been demonstrated . Conversely, postoperative hamstring weakness at 5 to 8 months was more pronounced in the HT group compared with the QT group . Other studies have reported similar results, with initial postoperative extensor strength deficits but equal results one year following ACL-R with QT [19, 29]. Isokinetic hamstring:quadriceps ratios are significantly higher for QT compared to HT [82, 117].
When using HT, isokinetic flexor strength is significantly reduced compared to QT, and the deficit may persist for up to two years [19, 29, 70]. Similar data, with no difference in extensor strength but decreased flexor strength when using HT, is also reported when comparing BPTB and HT [6, 42, 67]. Interestingly, a recent study showed that maximal hamstring strength, but not explosive hamstring strength improved over time following ACL-R using HT . Comparing QT to BPTB, similar levels of quadriceps recovery have been observed in the short term [39, 51].
Return to sport
Return to sport (RTS) following ACL-R is a commonly utilized and clinically important outcome measure. Despite its prevalence, this outcome is often reported in a variety of ways, making it difficult to compare patient subgroups. A meta-analysis found an overall 82% RTS rate following ACL-R, however the rate dropped to 63% when looking at RTS at the same level . Many factors are thought to impact RTS including patient factors such as age, gender, compliance with rehabilitation, and patient confidence, as well as surgical factors such as concomitant injuries and graft choice.
There are few studies in the literature specifically comparing graft choice and its impact on successful RTS, but the consensus appears to find no difference between various graft types. Currently, the literature shows no difference between BPTB and HT in RTS rates. A study focusing on 100 soccer players who underwent ACL-R with either BPTB or HT revealed an overall return to play rate of 72% at 1 year follow up with 85% of those patients returning at the same level or higher . This study highlighted that graft choice did not predict RTS rates . Similarly, a case control study looking at athletes under the age of 25 revealed a non-statistically significant difference in return to preinjury activity level between BPTB patients (57%) and HT patients (43%) . A recent meta-analysis looking at 2,348 athletes had similar findings, with no difference between HT and BPTB in initial return rates (81% and 71%, respectively), as well as no difference between rates of return to preinjury level (50% and 49%, respectively) .
In regard to QT, a retrospective study looking at 5-year follow up for 291 young active patients demonstrated a 73% RTS at preinjury level with a mean time of 8 months to return . Although RTS rates for QT appear promising, there are few high-level studies comparing RTS rates with other graft types. A recent randomized controlled trial looking at patients 18 years or older who were randomized to ACL-R with either HT or QT revealed no difference in mean time to RTS at 2-year follow-up . Similarly, a prospective cohort study of 875 patients revealed no difference RTS rates at preinjury level when comparing QT (67%) and HT (74%) .
While allograft is an uncommon graft choice in young athletes, the literature frequently reports no difference in RTS rates between autograft and allograft. A recent study compared 78 collegiate level soccer players who underwent ACLR with BPTB (66%), HT (17%), allograft (10%), and QT (1%). The overall mean RTS time was 6 months. There was no difference in RTS rates based on graft selection when comparing all autograft and allograft patients (QT: 100%, BPTB: 90%, HT: 77%, allograft: 75%) . Conversely, a separate study compared 182 collegiate football players who underwent ACL-R with BPTB, HT, or allograft. Overall, 85% of players had autograft and 15% allograft, with the results indicating a significantly higher RTS rate of 85% in autograft compared to 69% in allograft patients .
While the current literature highlights that there may be no difference in RTS following ACL-R with various graft types, there is a need for further research on how to improve rates of return to the same level of sport amongst all graft types.
Complications and donor site morbidity
Surgical techniques continuously evolve not only to improve functional postoperative outcomes, but also to decrease complications and donor site morbidity. Knowledge of the various advantages and disadvantages of each graft option is fundamental to individualized ACL-R. Of course, one of the primary benefits of allograft use is the avoidance of donor site morbidity.
When considering complications and donor site morbidity related to graft choice, it is important to distinguish between minor and major complications. Minor donor site morbidities include persistent anterior knee pain, sensory loss of the lower leg, donor-site tendinopathy, scarring, cosmetic issues, and discomfort during kneeling (in patients without daily kneeling activities). Major complications besides graft rupture and contralateral ACL rupture include kneeling pain in patients who kneel during daily living, patellar fracture, extensor tendon rupture, and infection.
Anterior knee and kneeling pain is the most common postoperative complication related to graft choice, reported in up to 21.5% of patients . Evidence suggests that patients treated with BPTB have a significantly higher incidence (up to 72%) of postoperative anterior knee and kneeling pain compared to those treated with HT (up to 44%) or QT (up to 9.3%), possibly attributable to injury of the infrapatellar nerve and/or irritating of the Hoffa fat pad during BPTB harvest [10, 33, 41, 81, 92, 104, 110, 111, 118, 125]. When comparing HT to QT, no significant differences [2, 92, 119, 127] or slightly better outcomes were reported for QT [71, 110]. These favorable outcomes for QT over HT were supported by a recent metanalysis .
While minor donor site morbidities are irritating, severe complications like patellar fracture or extensor tendon rupture have a major impact on a patient's life and recovery. Patella fracture after ACL-R with autograft using bone blocks ranges between 0.1% and 2% [39, 45, 61, 123], but may be as high as 8.8% when including occult fractures . Recently safe zones for bone block harvest have been described. A precise surgical technique is recommended, with harvest localization medial to midline and without exceeding 50% of the patellar thickness and patellar height [30, 93]. Compared to patella fractures, ruptures of the quadriceps or patella tendon after ACL-R are even rarer 1% and mainly reported only as case reports [69, 83, 87, 118].
Superficial and deep surgical site infection (SSI) after ACL-R is a rare but major complication, with an incidence between 0.32% and 1.1% [64, 75, 80]. Recently, evidence has emerged showing graft choice has an influence on the rate of postoperative SSI [64, 75, 80]. An up to eight times higher risk of SSI was reported in patients treated with HT compared to those with BPTB . These findings have been confirmed by a recent large, single-center study showing that HT and allograft are associated with a five times higher risk of postoperative infection compared to BPTB . When comparing all four graft options, QT seems to have the lowest rate of infection. The reason for differing rates of SSI with different graft options remains unclear, however contamination after harvest or preparation has been observed in up to 59.4% of cases and is the most accepted hypothesis [101, 132].
Compared to autografts, allografts have the advantage of reduced surgical time, lower donor site morbidity, and more predictable graft size but are believed to have a higher infection rate compared to autografts [20, 50]. Although rare, there is a risk of contamination of the implanted allograft and pathogens are often highly virulent, such as Clostridium or other bowel microorganisms .
With all graft options having advantages and drawbacks (Table 1), graft choice must be individualized and chosen in accordance with the patient. For primary ACL-R in adults, the authors prefer QT or allograft. For younger and active patients, the authors prefer QT-A because of its favorable biomechanical characteristics, predictable size, and faster incorporation compared to allograft (for details see “Current Trends In Graft Choice For Primary Anterior Cruciate Ligament Reconstruction—Part 1”). QT also demonstrates lower donor site morbidity compared to BPTB-A and a tendency towards lower graft re-rupture rates compared to HT, especially in highly active patients. Particularly in young and high-level athletes, the authors do not recommend the use of allograft, mainly due to the slower graft incorporation process which may result in excessive mechanical graft stress and higher failure rates when paired with the desire to quickly return to sport. In contrast, in older and less active patients, allograft is preferred due to shorter surgical times, lower donor site morbidity, and comparable PROs compared to autograft.
Graft choice affects postoperative outcomes after ACL-R and normal knee kinematics is not fully restored after surgery. Patients with hamstring tendon autograft may experience an increase in ATT and a decrease in flexion strength compared to those treated with BPTB or QT. Contrary, extensor strength is affected in patients with BPTB and QT. While patient reported outcomes are not influenced by graft choice, evidence suggests favorable postoperative graft rupture rates in patients treated with BPTB and QT autografts over HT or allografts. With regards to return to sports the consensus appears to find no difference between various graft types. Postoperative donor site morbidity is highest in BPTB, comparable between HT and QT and absent in allografts. With all graft options having advantages and drawbacks, graft choice must be individualized and chosen in accordance with the patient.
Ajrawat P, Dwyer T, Whelan D, Theodoropoulos J, Murnaghan L, Bhargava M, Ogilvie-Harris D, Chahal J (2021) A comparison of quadriceps tendon autograft with bone-patellar tendon-bone autograft and hamstring tendon autograft for primary anterior cruciate ligament reconstruction: a systematic review and quantitative synthesis. Clin J Sport Med 31(4):392–399
Akoto R, Albers M, Balke M, Bouillon B, Hoher J (2019) ACL reconstruction with quadriceps tendon graft and press-fit fixation versus quadruple hamstring graft and interference screw fixation - a matched pair analysis after one year follow up. BMC Musculoskelet Disord 20(1):109
Andernord D, Bjornsson H, Petzold M, Eriksson BI, Forssblad M, Karlsson J, Samuelsson K (2014) Surgical predictors of early revision surgery after anterior cruciate ligament reconstruction: results from the Swedish national knee ligament register on 13,102 patients. Am J Sports Med 42(7):1574–1582
Anderst W, Irrgang JJ, Fu FH, Tashman S, Karlsson J, Musahl V (2022) In search of a gold standard for objective clinical outcome: using dynamic biplane radiography to measure knee kinematics. Knee Surg, Sports Traumatol, Arthrosc 30(5):1499–1501
Ardern CL, Webster KE, Taylor NF, Feller JA (2011) Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med 45(7):596–606
Arida C, Tsikrikas CG, Mastrokalos DS, Panagopoulos A, Vlamis J, Triantafyllopoulos IK (2021) Comparison of bone-patella tendon-bone and four-strand hamstring tendon grafts for anterior cruciate ligament reconstruction: a prospective study. Cureus 13(11):e19197
Arnold MP, Calcei JG, Vogel N, Magnussen RA, Clatworthy M, Spalding T, Campbell JD, Bergfeld JA, Sherman SL, Group ACLS (2021) ACL Study Group survey reveals the evolution of anterior cruciate ligament reconstruction graft choice over the past three decades. Knee Surg Sports Traumatol Arthrosc 29(11):3871–3876
Barié A, Sprinckstub T, Huber J, Jaber A (2020) Quadriceps tendon vs. patellar tendon autograft for ACL reconstruction using a hardware-free press-fit fixation technique: comparable stability, function and return-to-sport level but less donor site morbidity in athletes after 10 years. Arch Orthop Trauma Surg 140(10):1465–1474
Belk JW, Kraeutler MJ, Marshall HA, Goodrich JA, McCarty EC (2018) Quadriceps tendon autograft for primary anterior cruciate ligament reconstruction: a systematic review of comparative studies with minimum 2-year follow-up. Arthroscopy 34(5):1699–1707
Bjornsson H, Samuelsson K, Sundemo D, Desai N, Sernert N, Rostgard-Christensen L, Karlsson J, Kartus J (2016) A randomized controlled trial with mean 16-year follow-up comparing hamstring and patellar tendon autografts in anterior cruciate ligament reconstruction. Am J Sports Med 44(9):2304–2313
Bottoni CR, Smith EL, Shaha J, Shaha SS, Raybin SG, Tokish JM, Rowles DJ (2015) Autograft versus allograft anterior cruciate ligament reconstruction: a prospective, randomized clinical study with a minimum 10-year follow-up. Am J Sports Med 43(10):2501–2509
Brophy RH, Schmitz L, Wright RW, Dunn WR, Parker RD, Andrish JT, McCarty EC, Spindler KP (2012) Return to play and future ACL injury risk after ACL reconstruction in soccer athletes from the Multicenter Orthopaedic Outcomes Network (MOON) group. The Am J Sports Med 40(11):2517–2522
Carpenter RD, Majumdar S, Ma CB (2009) Magnetic resonance imaging of 3-dimensional in vivo tibiofemoral kinematics in anterior cruciate ligament-reconstructed knees. Arthroscopy 25(7):760–766
Castoldi M, Magnussen RA, Gunst S, Batailler C, Neyret P, Lustig S, Servien E (2020) A randomized controlled trial of bone-patellar tendon-bone anterior cruciate ligament reconstruction with and without lateral extra-articular tenodesis: 19-year clinical and radiological follow-up. Am J Sports Med 48(7):1665–1672
Cavaignac E, Coulin B, Tscholl P, Nik Mohd Fatmy N, Duthon V, Menetrey J (2017) Is quadriceps tendon autograft a better choice than hamstring autograft for anterior cruciate ligament reconstruction? A comparative study with a mean follow-up of 3.6 years. Am J Sports Med 45(6):1326–1332
Chen H, Tie K, Qi Y, Li B, Chen B, Chen L (2017) Anteromedial versus transtibial technique in single-bundle autologous hamstring ACL reconstruction: a meta-analysis of prospective randomized controlled trials. J Orthop Surg Res 12(1):167
Cronstrom A, Tengman E, Hager CK (2023) Return to sports: a risky business? A systematic review with meta-analysis of risk factors for graft rupture following ACL reconstruction. Sports Med 53(1):91–110
Cruz AI Jr, Beck JJ, Ellington MD, Mayer SW, Pennock AT, Stinson ZS, VandenBerg CD, Barrow B, Gao B, Ellis HB Jr (2020) Failure rates of autograft and allograft ACL reconstruction in patients 19 years of age and younger: a systematic review and meta-analysis. JB JS Open Access 5(4):e2000106
Csapo R, Hoser C, Gfoller P, Raschner C, Fink C (2019) Fitness, knee function and competition performance in professional alpine skiers after ACL injury. J Sci Med Sport 22(Suppl 1):S39–S43
Cusumano A, Capitani P, Messina C, De Girolamo L, Viganò M, Ravasio G, Facchini F, Sconfienza LM, Zerbi A, Schoenhuber H, Pozzoni R, Thiébat G (2022) Different timing in allograft and autograft maturation after primary anterior cruciate ligament reconstruction does not influence the clinical outcome at mid-long-term follow-up. Knee Surg, Sports Traumatol, Arthrosc 30(7):2281–2290
Dai W, Leng X, Wang J, Cheng J, Hu X, Ao Y (2022) Quadriceps tendon autograft versus bone-patellar tendon-bone and hamstring tendon autografts for anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Am J Sports Med 50(12):3425–3439
Daruwalla JH, Greis PE, Hancock R, Xerogeanes JW (2014) Rates and determinants of return to play after anterior cruciate ligament reconstruction in NCAA division 1 college football athletes: a study of the ACC, SEC, and PAC-12 conferences. Orthop J Sports Med 2(8):2325967114543901
DeFazio MW, Curry EJ, Gustin MJ, Sing DC, Abdul-Rassoul H, Ma R, Fu F, Li X (2020) Return to sport after ACL reconstruction with a BTB versus hamstring tendon autograft: a systematic review and meta-analysis. Orthop J Sports Med 8(12):2325967120964919
Dhillon J, Kraeutler MJ, Belk JW, Mccarty EC, Mcculloch PC, Scillia AJ (2022) Autograft and nonirradiated allograft for anterior cruciate ligament reconstruction demonstrate similar clinical outcomes and graft failure rates: an updated systematic review. Arthrosc, Sports Med Rehabil 4(4):e1513–e1521
Duerr RA, Ormseth B, DiBartola A, Geers K, Kaeding CC, Siston R, Flanigan DC, Magnussen RA (2023) Association of elevated posterior tibial slope with revision anterior cruciate ligament graft failure in a matched cohort analysis. Am J Sports Med 51(1):38–48
Edgar CM, Zimmer S, Kakar S, Jones H, Schepsis AA (2008) Prospective comparison of auto and allograft hamstring tendon constructs for ACL reconstruction. Clin Orthop Relat Res 466(9):2238–2246
Ellis HB, Matheny LM, Briggs KK, Pennock AT, Steadman JR (2012) Outcomes and revision rate after bone-patellar tendon-bone allograft versus autograft anterior cruciate ligament reconstruction in patients aged 18 years or younger with closed physes. Arthroscopy 28(12):1819–1825
Fares A, Horteur C, Abou Al Ezz M, Hardy A, Rubens-Duval B, Karam K, Gaulin B, Pailhe R (2022) Posterior tibial slope (PTS) >/= 10 degrees is a risk factor for further anterior cruciate ligament (ACL) injury; BMI is not. Eur J Orthop Surg Traumatol. https://doi.org/10.1007/s00590-022-03406-9
Fischer F, Fink C, Herbst E, Hoser C, Hepperger C, Blank C, Gfoller P (2018) Higher hamstring-to-quadriceps isokinetic strength ratio during the first post-operative months in patients with quadriceps tendon compared to hamstring tendon graft following ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 26(2):418–425
Fu FH, Rabuck SJ, West RV, Tashman S, Irrgang JJ (2019) Patellar fractures after the harvest of a quadriceps tendon autograft with a bone block: a case series. Orthop J Sports Med 7(3):2325967119829051
Gabler CM, Jacobs CA, Howard JS, Mattacola CG, Johnson DL (2016) Comparison of graft failure rate between autografts placed via an anatomic anterior cruciate ligament reconstruction technique: a systematic review, meta-analysis, and meta-regression. Am J Sports Med 44(4):1069–1079
Galan H, Escalante M, Della Vedova F, Slullitel D (2020) All inside full thickness quadriceps tendon ACL reconstruction: long term follow up results. J Exp Orthop 7(1):13
Geib TM, Shelton WR, Phelps RA, Clark L (2009) Anterior cruciate ligament reconstruction using quadriceps tendon autograft: intermediate-term outcome. Arthroscopy 25(12):1408–1414
Gifstad T, Sole A, Strand T, Uppheim G, Grøntvedt T, Drogset JO (2013) Long-term follow-up of patellar tendon grafts or hamstring tendon grafts in endoscopic ACL reconstructions. Knee Surg, Sports Traumatol, Arthrosc 21(3):576–583
Gifstad T, Foss OA, Engebretsen L, Lind M, Forssblad M, Albrektsen G, Drogset JO (2014) Lower risk of revision with patellar tendon autografts compared with hamstring autografts: a registry study based on 45,998 primary ACL reconstructions in Scandinavia. Am J Sports Med 42(10):2319–2328
Goetz G, de Villiers C, Sadoghi P, Geiger-Gritsch S (2020) allograft for Anterior Cruciate Ligament Reconstruction (ACLR): a systematic review and meta-analysis of long-term comparative effectiveness and safety. Results of a health technology assessment. Arthrosc Sports Med Rehabil 2(6):e873–e891
Gorschewsky O, Klakow A, Putz A, Mahn H, Neumann W (2007) Clinical comparison of the autologous quadriceps tendon (BQT) and the autologous patella tendon (BPTB) for the reconstruction of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 15(11):1284–1292
Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA (2016) Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med 50(13):804–808
Han HS, Seong SC, Lee S, Lee MC (2008) Anterior cruciate ligament reconstruction : quadriceps versus patellar autograft. Clin Orthop Relat Res 466(1):198–204
Hashemi J, Chandrashekar N, Mansouri H, Gill B, Slauterbeck JR, Schutt RC Jr, Dabezies E, Beynnon BD (2010) Shallow medial tibial plateau and steep medial and lateral tibial slopes: new risk factors for anterior cruciate ligament injuries. Am J Sports Med 38(1):54–62
He X, Yang XG, Feng JT, Wang F, Huang HC, He JQ, Hu YC (2020) Clinical outcomes of the central third patellar tendon versus four-strand hamstring tendon autograft used for anterior cruciate ligament reconstruction: a systematic review and subgroup meta-analysis of randomized controlled trials. Injury 51(8):1714–1725
Heijne A, Hagstromer M, Werner S (2015) A two- and five-year follow-up of clinical outcome after ACL reconstruction using BPTB or hamstring tendon grafts: a prospective intervention outcome study. Knee Surg Sports Traumatol Arthrosc 23(3):799–807
Herbawi F, Lozano-Lozano M, Lopez-Garzon M, Postigo-Martin P, Ortiz-Comino L, Martin-Alguacil JL, Arroyo-Morales M, Fernandez-Lao C (2022) A systematic review and meta-analysis of strength recovery measured by isokinetic dynamometer technology after anterior cruciate ligament reconstruction using quadriceps tendon autografts vs. hamstring tendon autografts or patellar tendon autografts. Int J Environ Res Public Health 19(11):6764
Hofbauer M, Thorhauer ED, Abebe E, Bey M, Tashman S (2014) Altered tibiofemoral kinematics in the affected knee and compensatory changes in the contralateral knee after anterior cruciate ligament reconstruction. Am J Sports Med 42(11):2715–2721
Hogan DW, Burch MB, Rund JM, Geeslin DW, Ma R, Gray AF, Chu CR, Ray TE, Pullen WM, Sherman SL (2022) No difference in complication rates or patient-reported outcomes between bone-patella tendon-bone and quadriceps tendon autograft for anterior cruciate ligament reconstruction. Arthrosc Sports Med Rehabil 4(2):e417–e424
Holm I, Oiestad BE, Risberg MA, Aune AK (2010) No difference in knee function or prevalence of osteoarthritis after reconstruction of the anterior cruciate ligament with 4-strand hamstring autograft versus patellar tendon-bone autograft: a randomized study with 10-year follow-up. Am J Sports Med 38(3):448–454
Horstmann H, Petri M, Tegtbur U, Felmet G, Krettek C, Jagodzinski M (2022) Quadriceps and hamstring tendon autografts in ACL reconstruction yield comparably good results in a prospective, randomized controlled trial. Arch Orthop Trauma Surg 142(2):281–289
Howard JS, Lembach ML, Metzler AV, Johnson DL (2016) Rates and determinants of return to play after anterior cruciate ligament reconstruction in national collegiate athletic association division i soccer athletes: a study of the Southeastern conference. Am J Sports Med 44(2):433–439
Hughes JD, Burnham JM, Hirsh A, Musahl V, Fu FH, Irrgang JJ, Lynch AD (2019) Comparison of short-term biodex results after anatomic anterior cruciate ligament reconstruction among 3 autografts. Orthop J Sports Med 7(5):2325967119847630
Hulet C, Sonnery-Cottet B, Stevenson C, Samuelsson K, Laver L, Zdanowicz U, Stufkens S, Curado J, Verdonk P, Spalding T (2019) The use of allograft tendons in primary ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 27(6):1754–1770
Hunnicutt JL, Gregory CM, McLeod MM, Woolf SK, Chapin RW, Slone HS (2019) Quadriceps recovery after anterior cruciate ligament reconstruction with quadriceps tendon versus patellar tendon autografts. Orthop J Sports Med 7(4):2325967119839786
Hurley ET, Mojica ES, Kanakamedala AC, Meislin RJ, Strauss EJ, Campbell KA, Alaia MJ (2022) Quadriceps tendon has a lower re-rupture rate than hamstring tendon autograft for anterior cruciate ligament reconstruction - a meta-analysis. J ISAKOS 7(2):87–93
Iliopoulos E, Galanis N, Zafeiridis A, Iosifidis M, Papadopoulos P, Potoupnis M, Geladas N, Vrabas IS, Kirkos J (2017) Anatomic single-bundle anterior cruciate ligament reconstruction improves walking economy: hamstrings tendon versus patellar tendon grafts. Knee Surg Sports Traumatol Arthrosc 25(10):3155–3162
Irvine JN, Arner JW, Thorhauer E, Abebe ES, D’Auria J, Schreiber VM, Harner CD, Tashman S (2016) Is there a difference in graft motion for bone-tendon-bone and hamstring autograft ACL reconstruction at 6 weeks and 1 year? Am J Sports Med 44(10):2599–2607
Isaac DL, Beard DJ, Price AJ, Rees J, Murray DW, Dodd CA (2005) In-vivo sagittal plane knee kinematics: ACL intact, deficient and reconstructed knees. Knee 12(1):25–31
Johnston PT, McClelland JA, Feller JA, Webster KE (2021) Knee muscle strength after quadriceps tendon autograft anterior cruciate ligament reconstruction: systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 29(9):2918–2933
Kaeding CC, Pedroza AD, Reinke EK, Huston LJ, Consortium M Spindler KP (2015) Risk factors and predictors of subsequent ACL injury in either knee after ACL reconstruction: prospective analysis of 2488 primary ACL reconstructions From the MOON Cohort. Am J Sports Med 43(7):1583–1590
Kaeding CC, Pedroza AD, Reinke EK, Huston LJ, Hewett TE, Flanigan DC, Group MK, Spindler KP (2017) Change in anterior cruciate ligament graft choice and outcomes over time. Arthroscopy 33(11):2007–2014
Kan SL, Yuan ZF, Ning GZ, Yang B, Li HL, Sun JC, Feng SQ (2016) Autograft versus allograft in anterior cruciate ligament reconstruction: a meta-analysis with trial sequential analysis. Medicine (Baltimore) 95(38):e4936
Karpinski K, Haner M, Bierke S, Diermeier T, Petersen W (2021) Comparing knee laxity after anatomic anterior cruciate ligament reconstruction using quadriceps tendon versus semitendinosus tendon graft. Orthop J Sports Med 9(7):23259671211014850
Kim SJ, Kumar P, Oh KS (2009) Anterior cruciate ligament reconstruction: autogenous quadriceps tendon-bone compared with bone-patellar tendon-bone grafts at 2-year follow-up. Arthroscopy 25(2):137–144
Kim SJ, Lee SK, Choi CH, Kim SH, Kim SH, Jung M (2014) Graft selection in anterior cruciate ligament reconstruction for smoking patients. Am J Sports Med 42(1):166–172
Kraeutler MJ, Bravman JT, McCarty EC (2013) Bone-patellar tendon-bone autograft versus allograft in outcomes of anterior cruciate ligament reconstruction: a meta-analysis of 5182 patients. Am J Sports Med 41(10):2439–2448
Kraus Schmitz J, Lindgren V, Edman G, Janarv P-M, Forssblad M, Stålman A (2021) Risk factors for septic arthritis after anterior cruciate ligament reconstruction: a nationwide analysis of 26,014 ACL reconstructions. Am J Sports Med 49(7):1769–1776
Kvist J, Kartus J, Karlsson J, Forssblad M (2014) Results from the Swedish national anterior cruciate ligament register. Arthroscopy 30(7):803–810
Lansdown DA, Riff AJ, Meadows M, Yanke AB, Bach BR Jr (2017) What factors influence the biomechanical properties of allograft tissue for ACL reconstruction? A systematic review. Clin Orthop Relat Res 475(10):2412–2426
Lautamies R, Harilainen A, Kettunen J, Sandelin J, Kujala UM (2008) Isokinetic quadriceps and hamstring muscle strength and knee function 5 years after anterior cruciate ligament reconstruction: comparison between bone-patellar tendon-bone and hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc 16(11):1009–1016
Lawhorn KW, Howell SM, Traina SM, Gottlieb JE, Meade TD, Freedberg HI (2012) The effect of graft tissue on anterior cruciate ligament outcomes: a multicenter, prospective, randomized controlled trial comparing autograft hamstrings with fresh-frozen anterior tibialis allograft. Arthroscopy 28(8):1079–1086
Lee GH, McCulloch P, Cole BJ, Bush-Joseph CA, Bach BR Jr (2008) The incidence of acute patellar tendon harvest complications for anterior cruciate ligament reconstruction. Arthroscopy 24(2):162–166
Lee JK, Lee S, Lee MC (2016) Outcomes of anatomic anterior cruciate ligament reconstruction: bone-quadriceps tendon graft versus double-bundle hamstring tendon graft. Am J Sports Med 44(9):2323–2329
Lind M, Nielsen TG, Soerensen OG, Mygind-Klavsen B, Faunø P (2020) Quadriceps tendon grafts does not cause patients to have inferior subjective outcome after anterior cruciate ligament (ACL) reconstruction than do hamstring grafts: a 2-year prospective randomised controlled trial. Br J Sports Med 54(3):183–187
Liu Y, Liu X, Liu Y, Yang S (2022) Comparison of clinical outcomes of using the nonirradiated and irradiated allograft for anterior cruciate ligament (ACL) reconstruction: A systematic review update and meta-analysis. Medicine (Baltimore) 101(32):e29990
Lund B, Nielsen T, Faunø P, Christiansen SE, Lind M (2014) Is quadriceps tendon a better graft choice than patellar tendon? a prospective randomized study. Arthroscopy 30(5):593–598
Maletis GB, Inacio MC, Desmond JL, Funahashi TT (2013) Reconstruction of the anterior cruciate ligament: association of graft choice with increased risk of early revision. Bone Joint J 95-B(5):623–628
Maletis GB, Inacio MC, Reynolds S, Desmond JL, Maletis MM, Funahashi TT (2013) Incidence of postoperative anterior cruciate ligament reconstruction infections: graft choice makes a difference. Am J Sports Med 41(8):1780–1785
Maletis GB, Inacio MC, Funahashi TT (2015) Risk factors associated with revision and contralateral anterior cruciate ligament reconstructions in the Kaiser Permanente ACLR registry. Am J Sports Med 43(3):641–647
Maletis GB, Chen J, Inacio MC, Funahashi TT (2016) Age-related risk factors for revision anterior cruciate ligament reconstruction: a cohort study of 21,304 patients from the Kaiser Permanente anterior cruciate ligament registry. Am J Sports Med 44(2):331–336
Maletis GB, Chen J, Inacio MCS, Love RM, Funahashi TT (2017) Increased risk of revision after anterior cruciate ligament reconstruction with bone-patellar tendon-bone allografts compared with autografts. Am J Sports Med 45(6):1333–1340
Maletis GB, Chen J, Inacio MCS, Love RM, Funahashi TT (2017) Increased risk of revision after anterior cruciate ligament reconstruction with soft tissue allografts compared with autografts: graft processing and time make a difference. Am J Sports Med 45(8):1837–1844
Marom N, Kapadia M, Nguyen JT, Ammerman B, Boyle C, Wolfe I, Halvorsen KC, Miller AO, Henry MW, Brause BD, Hannafin JA, Marx RG, Ranawat AS (2022) Factors associated with an intra-articular infection after anterior cruciate ligament reconstruction: a large single-institution cohort study. Am J Sports Med 50(5):1229–1236
Marques FDS, Barbosa PHB, Alves PR, Zelada S, Nunes RPDS, De Souza MR, Pedro MDAC, Nunes JF, Alves WM, De Campos GC (2020) Anterior knee pain after anterior cruciate ligament reconstruction. Orthop J Sports Med 8(10):232596712096108
Martin-Alguacil JL, Arroyo-Morales M, Martín-Gomez JL, Monje-Cabrera IM, Abellán-Guillén JF, Esparza-Ros F, Lozano ML, Cantarero-Villanueva I (2018) Strength recovery after anterior cruciate ligament reconstruction with quadriceps tendon versus hamstring tendon autografts in soccer players: a randomized controlled trial. Knee 25(4):704–714
Marumoto JM, Mitsunaga MM, Richardson AB, Medoff RJ, Mayfield GW (1996) Late patellar tendon ruptures after removal of the central third for anterior cruciate ligament reconstruction. A report of two cases. Am J Sports Med 24(5):698–701
Mascarenhas R, Tranovich MJ, Kropf EJ, Fu FH, Harner CD (2012) Bone-patellar tendon-bone autograft versus hamstring autograft anterior cruciate ligament reconstruction in the young athlete: a retrospective matched analysis with 2–10 year follow-up. Knee Surg Sports Traumatol Arthrosc 20(8):1520–1527
Mehta VM, Mandala C, Foster D, Petsche TS (2010) Comparison of revision rates in bone-patella tendon-bone autograft and allograft anterior cruciate ligament reconstruction. Orthopedics 33(1):12
Migliorini F, Eschweiler J, Mansy YE, Quack V, Tingart M, Driessen A (2020) Quadriceps tendon autograft for primary ACL reconstruction: a Bayesian network meta-analysis. Eur J Orthop Surg Traumatol 30(7):1129–1138
Miller MD, Nichols T, Butler CA (1999) Patella fracture and proximal patellar tendon rupture following arthroscopic anterior cruciate ligament reconstruction. Arthroscopy 15(6):640–643
Mohtadi N, Chan D, Barber R, Oddone Paolucci E (2015) A randomized clinical trial comparing patellar tendon, hamstring tendon, and double-bundle ACL reconstructions: patient-reported and clinical outcomes at a minimal 2-year follow-up. Clin J Sport Med 25(4):321–331
Mohtadi N, Chan D, Barber R, Paolucci EO (2016) Reruptures, reinjuries, and revisions at a minimum 2-year follow-up: a randomized clinical trial comparing 3 graft types for ACL reconstruction. Clin J Sport Med 26(2):96–107
Mohtadi NG, Chan DS, Dainty KN, Whelan DB (2011) Patellar tendon versus hamstring tendon autograft for anterior cruciate ligament rupture in adults. Cochrane Database Syst Rev. 2011(9):CD005960. https://doi.org/10.1002/14651858.CD005960.pub29):CD005960
Mouarbes D, Menetrey J, Marot V, Courtot L, Berard E, Cavaignac E (2019) Anterior cruciate ligament reconstruction: a systematic review and meta-analysis of outcomes for quadriceps tendon autograft versus bone-patellar tendon-bone and hamstring-tendon autografts. Am J Sports Med 47(14):3531–3540
Mouarbes D, Dagneaux L, Olivier M, Lavoue V, Peque E, Berard E, Cavaignac E (2020) Lower donor-site morbidity using QT autografts for ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 28(8):2558–2566
Negrin LL, Zeitler C, Hofbauer M (2021) Patellar size variation at the quadriceps tendon-bone block harvest site: a magnetic resonance imaging study to evaluate the safe zone for harvesting a sufficient bone block. Am J Sports Med 49(14):3850–3858
Nyland J, Collis P, Huffstutler A, Sachdeva S, Spears JR, Greene J, Caborn DNM (2020) Quadriceps tendon autograft ACL reconstruction has less pivot shift laxity and lower failure rates than hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc 28(2):509–518
Ortmaier R, Fink C, Schobersberger W, Kindermann H, Leister I, Runer A, Hepperger C, Blank C, Mattiassich G (2021) Return to sports after anterior cruciate ligament injury: a matched-pair analysis of repair with internal brace and reconstruction using hamstring or quadriceps tendons. Sportverletz Sportschaden 35(1):36–44
Pallis M, Svoboda SJ, Cameron KL, Owens BD (2012) Survival comparison of allograft and autograft anterior cruciate ligament reconstruction at the United States Military Academy. Am J Sports Med 40(6):1242–1246
Papannagari R, Gill TJ, Defrate LE, Moses JM, Petruska AJ, Li G (2006) In vivo kinematics of the knee after anterior cruciate ligament reconstruction: a clinical and functional evaluation. Am J Sports Med 34(12):2006–2012
Parkkari J, Pasanen K, Mattila VM, Kannus P, Rimpela A (2008) The risk for a cruciate ligament injury of the knee in adolescents and young adults: a population-based cohort study of 46 500 people with a 9 year follow-up. Br J Sports Med 42(6):422–426
Pennock AT, Johnson KP, Turk RD, Bastrom TP, Chambers HG, Boutelle KE, Edmonds EW (2019) Transphyseal anterior cruciate ligament reconstruction in the skeletally immature: quadriceps tendon autograft versus hamstring tendon autograft. Orthop J Sports Med 7(9):2325967119872450
Perez JR, Emerson CP, Barrera CM, Greif DN, Cade WH 2nd, Kaplan LD, Baraga MG (2019) Patient-reported knee outcome scores with soft tissue quadriceps tendon autograft are similar to bone-patellar tendon-bone autograft at minimum 2-year follow-up: a retrospective single-center cohort study in primary anterior cruciate ligament reconstruction surgery. Orthop J Sports Med 7(12):2325967119890063
Pérez-Prieto D, Portillo ME, Torres-Claramunt R, Pelfort X, Hinarejos P, Monllau JC (2018) Contamination occurs during ACL graft harvesting and manipulation, but it can be easily eradicated. Knee Surg, Sports Traumatol, Arthrosc 26(2):558–562
Persson A, Fjeldsgaard K, Gjertsen JE, Kjellsen AB, Engebretsen L, Hole RM, Fevang JM (2014) Increased risk of revision with hamstring tendon grafts compared with patellar tendon grafts after anterior cruciate ligament reconstruction: a study of 12,643 patients from the Norwegian cruciate ligament registry, 2004–2012. Am J Sports Med 42(2):285–291
Poehling GG, Curl WW, Lee CA, Ginn TA, Rushing JT, Naughton MJ, Holden MB, Martin DF, Smith BP (2005) Analysis of outcomes of anterior cruciate ligament repair with 5-year follow-up: allograft versus autograft. Arthroscopy 21(7):774–785
Poehling-Monaghan KL, Salem H, Ross KE, Secrist E, Ciccotti MC, Tjoumakaris F, Ciccotti MG, Freedman KB (2017) Long-term outcomes in anterior cruciate ligament reconstruction: a systematic review of patellar tendon versus hamstring autografts. Orthop J Sports Med 5(6):2325967117709735
Rahardja R, Zhu M, Love H, Clatworthy MG, Monk AP, Young SW (2020) Rates of revision and surgeon-reported graft rupture following ACL reconstruction: early results from the New Zealand ACL registry. Knee Surg Sports Traumatol Arthrosc 28(7):2194–2202
Rahardja R, Zhu M, Love H, Clatworthy MG, Monk AP, Young SW (2020) Effect of graft choice on revision and contralateral anterior cruciate ligament reconstruction: results from the New Zealand ACL REgistry. Am J Sports Med 48(1):63–69
Rahr-Wagner L, Thillemann TM, Pedersen AB, Lind M (2014) Comparison of hamstring tendon and patellar tendon grafts in anterior cruciate ligament reconstruction in a nationwide population-based cohort study: results from the danish registry of knee ligament reconstruction. Am J Sports Med 42(2):278–284
Rizvanovic D, Walden M, Forssblad M, Stalman A (2023) Surgeon's experience, sports participation and a concomitant MCL injury increase the use of patellar and quadriceps tendon grafts in primary ACL reconstruction: a nationwide registry study of 39,964 surgeries. Knee Surg Sports Traumatol Arthrosc 31(2):475-486
Runer A, Csapo R, Hepperger C, Herbort M, Hoser C, Fink C (2020) Anterior cruciate ligament reconstructions with quadriceps tendon autograft result in lower graft rupture rates but similar patient-reported outcomes as compared with hamstring tendon autograft: a comparison of 875 patients. Am J Sports Med 48(9):2195–2204
Runer A, Suter A, Roberti di Sarsina T, Jucho L, Gfoller P, Csapo R, Hoser C, Fink C (2022) Quadriceps tendon autograft for primary anterior cruciate ligament reconstruction show comparable clinical, functional, and patient-reported outcome measures, but lower donor-site morbidity compared with hamstring tendon autograft: A matched-pairs study with a mean follow-up of 6.5 years. J ISAKOS. https://doi.org/10.1016/j.jisako.2022.08.008S2059-7754(2022)00083-00089.
Runer A, Wierer G, Herbst E, Hepperger C, Herbort M, Gfoller P, Hoser C, Fink C (2018) There is no difference between quadriceps- and hamstring tendon autografts in primary anterior cruciate ligament reconstruction: a 2-year patient-reported outcome study. Knee Surg Sports Traumatol Arthrosc 26(2):605–614
Sajovic M, Stropnik D, Skaza K (2018) Long-term comparison of semitendinosus and gracilis tendon versus patellar tendon autografts for anterior cruciate ligament reconstruction: A 17-year follow-up of a randomized controlled trial. Am J Sports Med 46(8):1800–1808
Samuelsen BT, Webster KE, Johnson NR, Hewett TE, Krych AJ (2017) Hamstring autograft versus patellar tendon autograft for ACL reconstruction: is there a difference in graft failure rate? A meta-analysis of 47,613 patients. Clin Orthop Relat Res 475(10):2459–2468
San Jose AT, Maniar N, Timmins RG, Beerworth K, Hampel C, Tyson N, Williams MD, Opar DA (2023) Explosive hamstrings strength asymmetry persists despite maximal hamstring strength recovery following anterior cruciate ligament reconstruction using hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc 31(1):299–307
Schmidt T, Hoburg A, Broziat C, Smith MD, Gohs U, Pruss A, Scheffler S (2012) Sterilization with electron beam irradiation influences the biomechanical properties and the early remodeling of tendon allografts for reconstruction of the anterior cruciate ligament (ACL). Cell Tissue Banking 13(3):387–400
Schmitt LC, Paterno MV, Hewett TE (2012) The impact of quadriceps femoris strength asymmetry on functional performance at return to sport following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 42(9):750–759
Sinding KS, Nielsen TG, Hvid LG, Lind M, Dalgas U (2020) Effects of autograft types on muscle strength and functional capacity in patients having anterior cruciate ligament reconstruction: a randomized controlled trial. Sports Med 50(7):1393–1403
Singh H, Glassman I, Sheean A, Hoshino Y, Nagai K, de Sa D (2023) Less than 1% risk of donor-site quadriceps tendon rupture post-ACL reconstruction with quadriceps tendon autograft: a systematic review. Knee Surg Sports Traumatol Arthrosc 31(2):572–585
Sofu H, Sahin V, Gursu S, Yildirim T, Issin A, Ordueri M (2013) Use of quadriceps tendon versus hamstring tendon autograft for arthroscopic anterior cruciate ligament reconstruction: a comparative analysis of clinical results. Eklem Hastalik Cerrahisi 24(3):139–143
Tan TK, Subramaniam AG, Ebert JR, Radic R (2022) Quadriceps tendon versus hamstring tendon autografts for anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Am J Sports Med 50(14):3974–3986
Tashman S, Collon D, Anderson K, Kolowich P, Anderst W (2004) Abnormal rotational knee motion during running after anterior cruciate ligament reconstruction. Am J Sports Med 32(4):975–983
Tashman S, Zandiyeh P, Irrgang JJ, Musahl V, West RV, Shah N, Fu FH (2021) Anatomic single- and double-bundle ACL reconstruction both restore dynamic knee function: a randomized clinical trial—part II: knee kinematics. Knee Surg, Sports Traumatol, Arthrosc 29(8):2676–2683
Tay GH, Warrier SK, Marquis G (2006) Indirect patella fractures following ACL reconstruction: a review. Acta Orthop 77(3):494–500
Tejwani SG, Chen J, Funahashi TT, Love R, Maletis GB (2015) Revision risk after allograft anterior cruciate ligament reconstruction: association with graft processing techniques, patient characteristics, and graft type. Am J Sports Med 43(11):2696–2705
Thompson SM, Salmon LJ, Waller A, Linklater J, Roe JP, Pinczewski LA (2016) Twenty-year outcome of a longitudinal prospective evaluation of isolated endoscopic anterior cruciate ligament reconstruction with patellar tendon or hamstring autograft. Am J Sports Med 44(12):3083–3094
Tian S, Wang B, Liu L, Wang Y, Ha C, Li Q, Yang X, Sun K (2016) Irradiated hamstring tendon allograft versus autograft for anatomic double-bundle anterior cruciate ligament reconstruction: midterm clinical outcomes. Am J Sports Med 44(10):2579–2588
Todor A, Nistor DV, Caterev S (2019) Clinical outcomes after ACL reconstruction with free quadriceps tendon autograft versus hamstring tendons autograft. A retrospective study with a minimal follow-up two years. Acta Orthop Traumatol Turc 53(3):180–183
Wang HD, Zhu YB, Wang TR, Zhang WF, Zhang YZ (2018) Irradiated allograft versus autograft for anterior cruciate ligament reconstruction: A meta-analysis and systematic review of prospective studies. Int J Surg 49:45–55
Wasserstein D, Sheth U, Cabrera A, Spindler KP (2015) A systematic review of failed anterior cruciate ligament reconstruction with autograft compared with allograft in young patients. Sports Health 7(3):207–216
Webster KE, Feller JA, Hartnett N, Leigh WB, Richmond AK (2016) Comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction: a 15-year follow-up of a randomized controlled trial. Am J Sports Med 44(1):83–90
Winkler PW, Wagala NN, Hughes JD, Lesniak BP, Musahl V (2022) A high tibial slope, allograft use, and poor patient-reported outcome scores are associated with multiple ACL graft failures. Knee Surg, Sports Traumatol, Arthrosc 30(1):139–148
Wu C, Zhang X, Qiao Y, Chen J, Su W, Xu J, Ye Z, Jiang J, Xu C, Xie G, Zhao J, Zhao S (2022) Allograft contamination during suture preparation for anterior cruciate ligament reconstruction: an ex vivo study. Knee Surg, Sports Traumatol, Arthrosc 30(7):2400–2407
Xie X, Liu X, Chen Z, Yu Y, Peng S, Li Q (2015) A meta-analysis of bone-patellar tendon-bone autograft versus four-strand hamstring tendon autograft for anterior cruciate ligament reconstruction. Knee 22(2):100–110
Yang X-G, Wang F, He X, Feng J-T, Hu Y-C, Zhang H, Yang L, Hua K (2020) Network meta-analysis of knee outcomes following anterior cruciate ligament reconstruction with various types of tendon grafts. Int Orthop 44(2):365–380
Yoo SH, Song EK, Shin YR, Kim SK, Seon JK (2017) Comparison of clinical outcomes and second-look arthroscopic findings after ACL reconstruction using a hamstring autograft or a tibialis allograft. Knee Surg Sports Traumatol Arthrosc 25(4):1290–1297
Zeng C, Gao SG, Li H, Yang T, Luo W, Li YS, Lei GH (2016) Autograft versus allograft in anterior cruciate ligament reconstruction: a meta-analysis of randomized controlled trials and systematic review of overlapping systematic reviews. Arthroscopy 32(1):153-163 e118
Zhao D, Pan JK, Lin FZ, Luo MH, Liang GH, Zeng LF, Huang HT, Han YH, Xu NJ, Yang WY, Liu J (2022) Risk Factors for Revision or Rerupture After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med. https://doi.org/10.1177/036354652211197873635465221119787.
Zwolski C, Schmitt LC, Quatman-Yates C, Thomas S, Hewett TE, Paterno MV (2015) The influence of quadriceps strength asymmetry on patient-reported function at time of return to sport after anterior cruciate ligament reconstruction. Am J Sports Med 43(9):2242–2249
Emre Anil Özbek, MD was awarded a grant by ESSKA- University of Pittsburgh Sports Medicine Clinical and Research Fellowship, and The Scientific and Technological Research Council of Turkey (TUBITAK) outside the submitted work.
Open Access funding enabled and organized by Projekt DEAL.
Study performed at Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA.
The authors declare no conflict of interest with the present study.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Runer, A., Keeling, L., Wagala, N. et al. 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. J EXP ORTOP 10, 40 (2023). https://doi.org/10.1186/s40634-023-00601-3