AJSM - 2026-08-03 - Journal Article
Quadriceps Tendon Autografts Are Associated With Increased Short-term Reoperation Rates for Extension Deficit or Pain and Inferior Patient-Reported Outcomes Compared With Hamstring Tendon Autografts: An Analysis of 5653 Cases of Primary Anterior Cruciate Ligament Reconstruction.
Kekki C, Cristiani R, Stålman A, von Essen C
Topics
Key Takeaway
Quadriceps tendon autografts had a 19.2% overall reoperation rate at 2 years versus 8.9% for hamstring and 6.9% for BPTB, driven by a nearly twofold independent risk of reoperation for extension deficit or pain (OR 1.96).
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Summary
This retrospective cohort compared nonrevision reoperation rates and KOOS-based PROMs across HT, BPTB, and QT autografts in 5653 primary ACLRs from 2015–2022. QT autografts carried an 11.9% reoperation rate for extension deficit or pain versus 5.5% (HT) and 4.7% (BPTB), and were independently associated with this outcome (OR 1.96). QT patients also had lower odds of achieving the KOOS4 minimal important change (OR 0.56 vs. HT) and higher odds of treatment failure (OR 1.98), while female patients receiving larger QT grafts (9.5–12.0 mm) had 72% higher odds of reoperation for extension deficit or pain.
Key Limitation
Rehabilitation protocol heterogeneity across the study period and institutions was not controlled, making it impossible to determine whether the excess extension deficit reoperations reflect a graft-specific biological property or a systematic difference in postoperative management for QT patients.
Original Abstract
BACKGROUND
Anterior cruciate ligament reconstruction (ACLR) rates are rising, and quadriceps tendon (QT) autografts have gained popularity in recent years. Although QT autografts show objective and subjective outcomes comparable to hamstring tendon (HT) and bone-patellar tendon-bone (BPTB) autografts, nonrevision reoperations across graft types and their impact on patient-reported outcome measure (PROM) scores remain poorly studied.
PURPOSE
To compare nonrevision reoperation rates and PROM scores between primary ACLR using HT, BPTB, and QT autografts at 2 years' follow-up.
STUDY DESIGN
Cohort study; Level of evidence, 3.
METHODS
In this retrospective cohort study, 5653 primary ACLR procedures (2015-2022) were categorized by autograft type. Reoperations for extension deficit or pain, meniscal injuries, or cartilage injuries within 2 years were identified through medical records. Revision ACLR and graft failure were not included. Patient-reported outcomes were assessed preoperatively and at 2 years postoperatively using the Knee Injury and Osteoarthritis Outcome Score (KOOS). The minimal important change, patient acceptable symptom state, and treatment failure were evaluated using the KOOS 4 . Subgroup analysis examined associations between graft diameter, sex, and reoperations for extension deficit or pain.
RESULTS
The QT group had a higher overall reoperation rate (19.2%) than the HT (8.9%) and BPTB (6.9%) groups ( P < .001), driven by extension deficit or pain (11.9% vs 5.5% and 4.7%, respectively; P < .001). QT grafts remained independently associated with reoperations for extension deficit or pain after adjusting for confounders (odds ratio [OR], 1.96 [95% confidence interval (CI), 1.44-2.67]; P < .001). The QT group demonstrated lower odds of achieving the minimal important change than the HT (OR, 0.56 [95% CI, 0.41-0.77]; P < .001) and BPTB (OR, 0.48 [95% CI, 0.32-0.72]; P < .001) groups. The QT and BPTB groups showed higher odds of experiencing treatment failure (OR, 1.98 [95% CI, 1.21-3.23]; P = .01 and OR, 2.00 [95% CI, 1.10-3.63]; P = .02) and lower odds of achieving the patient acceptable symptom state (OR, 0.65 [95% CI, 0.49-0.85]; P = .002 and OR, 0.57 [95% CI, 0.41-0.79]; P < .001) than the HT group. On sex-stratified analysis, female patients demonstrated higher reoperation rates for extension deficit or pain than male patients (7.3% vs 5.5%, respectively; P = .01), and female patients receiving larger grafts (9.5-12.0 mm) demonstrated 72% higher odds of having this outcome (OR, 1.72 [95% CI, 1.14-2.56]; P = .01).
CONCLUSION
QT autografts were associated with significantly higher reoperation rates for extension deficit or pain and inferior PROM scores compared with HT autografts at 2 years after primary ACLR.