JBJS - 2026-03-12 - Journal Article
Comparison of Autograft Types in Anterior Cruciate Ligament Reconstruction: A Systematic Review and Bayesian Network Meta-Analysis of Randomized Clinical Trials.
Vosoughi F, Younesian S, Mousavi SM, Shaker F, Menbari Oskouie I
Topics
Key Takeaway
In a Bayesian NMA of 44 RCTs, QTB ranked highest for IKDC (SUCRA 90.1%), rotational stability, and graft survival, with a 74% lower risk of grade 2+ pivot-shift versus 4SST (RR 0.26).
Summary Depth
Choose how much analysis to show on this article page.
Summary
This Bayesian NMA asked which autograft yields superior functional, stability, and durability outcomes in primary ACLR by pooling 44 RCTs comparing 4SST, 4SSTG, 5SSTG, BPTB, QTB, and FQT. QTB was statistically superior to BPTB on IKDC (MD 3.46, 95% CrI 0.29–6.77) and carried a significantly lower risk of grade 2+ pivot-shift than 4SST (RR 0.26, 95% CrI 0.07–0.85). QTB also ranked highest for rerupture/revision risk reduction (SUCRA 83.3%), while BPTB ranked lowest for both IKDC and Lysholm.
Key Limitation
The statistically significant IKDC difference between QTB and BPTB (MD 3.46) falls below the established MCID for the IKDC subjective score (~11.5 points), limiting the clinical meaningfulness of the functional superiority claim.
Original Abstract
BACKGROUND
The literature regarding optimal autograft choice for anterior cruciate ligament (ACL) reconstruction (ACLR) remains inconclusive. This network meta-analysis (NMA) compares common autografts for primary ACLR.
METHODS
PubMed, Scopus, Web of Science, and Embase were searched up to May 3, 2025, for randomized clinical trials (RCTs) on primary ACLR in adults that compared ≥2 of the following tendon autografts: 4-strand semitendinosus (4SST), 4-strand semitendinosus-gracilis (4SSTG), its 5-strand variant (5SSTG), bone-patellar tendon-bone (BPTB), quadriceps tendon with bone (QTB), and free quadriceps tendon (FQT). Outcomes analyzed in the NMA were the International Knee Documentation Committee (IKDC) subjective score, Lysholm score, Tegner Activity Scale, anteroposterior (instrumented) and rotational (pivot-shift) stability, and rerupture or revision ACLR rate. Autografts were ranked using surface under the cumulative ranking (SUCRA) values.
RESULTS
A total of 44 RCTs with 3,491 patients were included in the NMA. With respect to the IKDC, QTB was statistically superior to BPTB (mean difference = 3.46, 95% credible interval [CrI]: 0.29 to 6.77), although the difference was likely not clinically meaningful. QTB ranked highest for the IKDC (SUCRA = 90.1%) and Tegner (SUCRA = 85.3%), while BPTB ranked lowest for the IKDC and Lysholm. With respect to knee laxity, QTB ranked second in anteroposterior and first in rotational stability, and it carried a significantly lower risk of a 2+ or higher pivot-shift than 4SST (risk ratio = 0.26, 95% CrI: 0.07 to 0.85). QTB was associated with a decreased risk of rerupture/revision compared with other autografts (SUCRA = 83.3%).
CONCLUSIONS
Based on the autograft rankings, QTB was found to lead to improved functional, activity-related, and stability outcomes overall, while also reducing the risk of graft failure.
LEVEL OF EVIDENCE
Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.