AJSM - 2026-04-01 - Journal Article; Comparative Study
Risk of Revision and Reoperation After ACL Reconstruction: Comparison of Quadriceps Tendon, Patellar Tendon, and Hamstring Autografts Stratified by Patient Sex and Age: A Cohort Study of 27,715 Patients From 2012 to 2023.
Lehman CR, Prentice HA, Reyes C, Mansfield C, Yang JS, Maletis GB
Topics
Key Takeaway
In females under 22, hamstring autograft carries 2.3× higher revision risk versus quadriceps tendon (HR 0.45) and 1.8× higher versus patellar tendon (HR 0.57) after ACL reconstruction.
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Summary
This Kaiser Permanente ACLR Registry cohort compared revision and reoperation risks across quadriceps tendon (QT), patellar tendon (PT), and hamstring tendon (HT) autografts in 27,715 primary isolated ACLR patients, stratified by sex and age (<22 vs ≥22 years). In females <22 years, HT carried significantly higher revision risk versus both QT (HR 0.45) and PT (HR 0.57), while QT and PT showed no difference in revision risk in any subgroup. QT and PT were associated with higher reoperation rates for stiffness and cartilage procedures compared to HT, particularly in males.
Key Limitation
Individual patient follow-up duration is not reported, making it impossible to assess whether revision risk differences persist or converge beyond the registry observation window.
Original Abstract
BACKGROUND
Many different graft choices exist for anterior cruciate ligament reconstruction (ACLR) with potential for variable outcomes based on graft type.
PURPOSE
To evaluate risk for subsequent surgical outcomes after primary ACLR according to autograft selection, stratified by patient sex and age.
STUDY DESIGN
Cohort study; Level of evidence, 3.
METHODS
Data from the Kaiser Permanente ACLR Registry was used to conduct a cohort study. A total of 27,715 patients with primary isolated autograft ACLR were identified (2012-2023). The exposure of interest was autograft type: quadriceps tendon (QT), patellar tendon (PT), or hamstring tendon (HT). Multivariable Cox proportional hazards regression models were used to evaluate the risk for revision and risk for ipsilateral reoperation according to autograft selection with adjustment for confounders.
RESULTS
No differences were found in revision or reoperation risks across sex and age groups for QT versus PT ACLR. For QT compared to HT ACLR, QT was associated with a lower revision risk in females <22 years (hazard ratio [HR], 0.45; 95% CI, 0.22-0.92). A higher risk of reoperation for stiffness (HR, 3.12; 95% CI, 1.00-9.72) and cartilage (HR, 3.65; 95% CI, 1.28-10.44) was observed with QT versus HT ACLR in males <22 years, while a higher overall reoperation risk (HR, 1.59; 95% CI, 1.06-2.40) was observed in males ≥22 years. When comparing PT to HT ACLR, PT had a lower risk of revision (HR, 0.57; 95% CI, 0.43-0.75) but a higher stiffness reoperation risk (HR, 1.58; 95% CI, 1.11-2.25) in females <22 years. PT versus HT was associated with higher overall reoperation (HR, 1.39; 95% CI, 1.12-1.73) and stiffness reoperation (HR, 1.56; 95% CI, 1.10-2.21) risks in males ≥22 years.
CONCLUSION
In young female patients, HT ACLR was associated with a 2.3 and 1.8 times higher revision risk when compared to QT and PT ACLR, respectively. No differences in risk of revision were noted between QT and PT ACLR. The risk for ipsilateral reoperation varied across patient age and sex, with higher risks observed for specific reoperation reasons with QT and PT compared to HT ACLR. Surgeons should consider these data when discussing risks and benefits of the different graft options for ACLR, especially with their female patients.