Anterior Cruciate Ligament Reconstruction with Quadriceps Tendon Autograft: Two-Year Functional Outcomes

Hrabovsky M¹, Dahl M², Berzins K³

Keywords: Anterior cruciate ligament reconstruction; Quadriceps

Abstract

Background: Bone-patellar tendon-bone (BPTB) and hamstring tendon (HT) autografts have long dominated anterior cruciate ligament reconstruction, but quadriceps tendon (QT) autograft has re-emerged as a mainstream option. Objective: To synthesise evidence on QT biomechanics, harvest, donor-site morbidity, and outcomes through two years and beyond, versus BPTB and HT. Methods: Narrative review of biomechanical, comparative, meta-analysis, imaging, and registry literature. Findings: QT provides a large, mechanically robust graft with donor-site pain markedly lower than BPTB and pooled re-rupture rates lower than HT (2.5% vs 8.7%). Two-year IKDC, Lysholm, and KOOS outcomes are comparable across grafts, with a modest Lysholm advantage for QT. Paediatric and revision evidence is encouraging but still maturing. Conclusions: QT autograft is a validated primary and revision option with favourable donor-site morbidity, though long-term data remain limited.

Keywords: anterior cruciate ligament reconstruction; quadriceps tendon autograft; hamstring tendon; bone-patellar tendon-bone; donor-site morbidity; functional outcomes

Introduction

Anterior cruciate ligament (ACL) rupture is one of the most common serious knee injuries in athletically active populations, with a population-based incidence of roughly 69 per 100,000 person-years and rising annual reconstruction volumes over the past two decades [1]. Graft choice remains the most consequential technical decision in ACL reconstruction, historically framed as a choice between BPTB autograft, prized for bone-to-bone healing and secure fixation, and HT autograft, favoured for lower anterior knee pain but historically associated with a higher failure rate in young, high-demand patients. QT autograft, first described as an alternative cruciate reconstruction graft three decades ago, has undergone a resurgence driven by refined harvest techniques, all-soft-tissue and bone-block fixation options, and an expanding comparative evidence base [2], summarised in a comprehensive review and systematic analysis of clinical results across the accumulated QT literature [3].

The choice among autografts is rarely dictated by any single outcome measure. BPTB affords rapid bone-to-bone tunnel incorporation but carries a well-documented burden of anterior knee pain, patellar fracture risk, and kneeling discomfort. HT autograft largely avoids anterior knee symptoms but has, in several registry analyses, been associated with a higher revision burden in young and highly active patients, and graft diameter can be unpredictable in smaller patients. QT autograft was proposed specifically to combine a mechanically robust, reproducibly large-diameter graft with a donor site remote from the patellar tendon-fat pad complex, and contemporary harvest instrumentation has made procurement more standardised and less invasive than in earlier descriptions.

This review synthesises the published literature on QT autograft for primary and revision ACL reconstruction: its biomechanical and anatomical rationale, harvest technique, comparative clinical and patient-reported outcomes at two years and beyond, donor-site morbidity, graft maturation on MRI, failure and re-rupture rates, and its use in paediatric/adolescent and revision populations. It is a narrative synthesis of the published literature rather than a report of a single institutional series.

Graft Biomechanics and Surgical Anatomy

Cryosectional and cadaveric studies established that the quadriceps tendon is a thick, broad structure whose central third provides a graft with cross-sectional area and tensile properties comparable to, or exceeding, those of the patellar tendon and considerably larger than a doubled hamstring strand [4]. Morphometric and biomechanical evaluation of the central quadriceps tendon confirmed adequate length and load-to-failure characteristics for cruciate reconstruction, while highlighting variability in thickness that necessitates individualised harvest planning [5]. Three-dimensional MRI reconstruction has since quantified this anatomical variability across sex and body habitus, informing preoperative graft-size prediction and harvest strategy [6]. Direct biomechanical testing of harvested QT grafts has confirmed structural properties adequate to withstand physiological in vivo loading during the early ligamentization period, supporting its biomechanical equivalence to BPTB and HT constructs (Table 1) [7]. Compared with a four-strand hamstring construct, the QT graft is obtained as a single broad strip rather than multiple smaller strands, reducing the risk of an undersized graft in patients with slender hamstrings and allowing the surgeon to titrate graft width against measured tunnel diameters at harvest.

QT graft can be harvested as an all-soft-tissue strip or with an attached patellar bone block, through open or minimally invasive incisions. A minimally invasive technique using a specialised cutting guide allows harvest of a full- or partial-thickness tendon graft, with or without a bone block, through a short proximal incision that avoids violating the joint or extensor mechanism insertion [8]. Full- versus partial-thickness harvest has not been shown to alter clinical outcomes, giving surgeons flexibility to tailor graft thickness to tunnel requirements. Bone-block fixation permits interference-screw fixation analogous to BPTB, while all-soft-tissue harvest allows suspensory cortical fixation and eliminates patellar fracture risk, at the cost of relying on soft-tissue tunnel healing. Because the harvest incision sits proximal to the joint line, the technique is compatible with concomitant meniscal, cartilage, and multiligament procedures, and avoids disturbing the patellar tendon should a future revision require a BPTB salvage graft.

Comparative Clinical Outcomes: Two-Year Evidence Base

A substantial body of randomised and cohort comparisons now exists (Table 2). Early series comparing QT-bone constructs with BPTB found equivalent IKDC and Lysholm outcomes at two years, with reduced anterior knee pain in the QT group [9,10]. A prospective randomised trial directly comparing QT and patellar tendon autografts found comparable stability, laxity, and functional scores, with less donor-site morbidity favouring QT [11]. Comparable equivalence was reported using a quadriceps-versus-patellar-bone construct in Korean cohorts [12]. Comparative work against HT autograft has similarly found no meaningful clinical difference: a two-year patient-reported outcome study found no difference in KOOS, IKDC, or Lysholm scores between QT and HT [13], while a longer 3.6-year comparative study reported broadly similar clinical performance between the two soft-tissue grafts [14]. The largest synthesis to date, pooling 27 studies and 2,856 patients, found no significant difference between QT and BPTB in Lysholm score, subjective IKDC, laxity, or graft failure, but significantly less donor-site pain with QT (risk ratio 0.25), and a modest but statistically significant Lysholm advantage for QT over HT (mean difference 3.81 points) [15]. A subsequent meta-analysis restricted to QT-versus-HT comparisons corroborated statistical equivalence in IKDC, Tegner, and graft-failure outcomes [16], and a further large meta-analysis of QT against both alternative grafts reached concordant conclusions [17]. Across these syntheses, QT reconstructs knee stability and restores patient-reported function indistinguishable from BPTB or HT, such that graft selection can reasonably be guided by secondary considerations — donor-site morbidity, fixation preference, revision-graft availability, and surgeon experience — rather than an expected difference in two-year outcome scores.

Donor-Site Morbidity

Donor-site morbidity is the outcome domain most consistently favouring QT. A network meta-analysis of 21 randomised trials (1,726 patients) found 88% lower odds of donor-site morbidity with QT and 69% lower odds with HT, each relative to BPTB (Figure 1) [18]. Ten-year follow-up of a randomised QT-versus-BPTB cohort using hardware-free press-fit fixation found comparable long-term stability and function (approximately 90% good-to-excellent Lysholm outcomes in both groups) but significantly greater persistent pain on kneeling and squatting in the BPTB group at both one and ten years [19]. These findings are consistent with the anterior knee pain profile documented in the earliest QT clinical series [10] and support QT as the graft with the lowest harvest-related morbidity among the three principal options. Quadriceps strength deficit is the morbidity most specific to QT harvest: early postoperative activation deficits are typically more pronounced than after hamstring harvest, though this has not been shown to translate into inferior strength, hop-test performance, or functional scores by two years, when symmetry indices generally converge across graft types.

Graft Maturation on MRI

Sequential MRI provides a non-invasive window into graft ligamentization. In adolescent athletes, QT autograft signal-intensity characteristics on MRI at one year differed from those of HT autograft, reflecting graft-specific remodelling trajectories rather than a uniform maturation timeline across graft types [20]. In skeletally immature athletes undergoing QT reconstruction, concomitant lateral extra-articular tenodesis was associated with improved graft maturity on MRI at two years, suggesting that adjunct extra-articular procedures may favourably influence the biological remodelling of QT grafts in high-risk younger patients [21]. These imaging findings complement, but do not yet fully explain, the comparative clinical failure-rate differences discussed below. Because graft maturation on MRI has not consistently correlated with clinical laxity or subjective outcome in mixed-graft cohorts, such findings are best regarded as hypothesis-generating markers of remodelling rather than validated criteria for individualising return-to-sport

Graft Failure, Re-Rupture, and Return to Sport

Re-rupture is the outcome of greatest concern in young, high-demand patients. A meta-analysis of 15 studies (611 QT, 543 HT patients) found a significantly lower pooled re-rupture rate with QT than HT (2.5% vs 8.7%; Figure 2) [22]. However, a large United States registry cohort of 21,973 primary ACL reconstructions found no significant difference in revision risk between QT and either BPTB (hazard ratio 1.06) or HT (hazard ratio 0.62), while HT carried significantly higher revision risk than BPTB (hazard ratio 1.52), underscoring that graft-specific failure risk estimates vary with study design, population, and surgical technique [23]. A systematic review focused specifically on outcomes at five years or later concluded that long-term comparative data for QT remain insufficient to firmly recommend it over HT or BPTB, despite favourable shorter-term signals [24]. Systematic review of adverse events after primary QT reconstruction has not identified an excess complication burden relative to historical alternative-graft series [25]. Return-to-sport reporting across the QT literature remains heterogeneous in definition and timepoint, so pooled rates should be interpreted cautiously until reporting is standardised.

Paediatric/Adolescent and Revision Applications

In skeletally immature and adolescent patients, a retrospective cohort comparison of QT and HT autografts found comparable functional recovery, revision rates, and return to sports participation, supporting QT as a viable option in this population when physeal-sparing technique is used [26]. In the revision setting, all-soft-tissue QT autograft has produced acceptable early and intermediate-term patient-reported outcomes after failed primary reconstruction [27], with comparable outcomes to BPTB autograft in revision ACL reconstruction among athletes at a minimum two-year follow-up [28]. Collectively, these data support QT as a versatile graft across the age and revision-complexity spectrum, complementing rather than replacing BPTB and HT. In skeletally immature patients, physeal-sparing or partial-transphyseal harvest avoids the epiphyseal disruption risk of certain bone-block grafts, while extra-articular tenodesis augmentation may help mitigate the higher baseline re-injury risk in younger patients returning to pivoting sport.

Conclusion

Three decades after its reintroduction as an alternative cruciate reconstruction graft [2], quadriceps tendon autograft has accumulated a robust two-year comparative evidence base demonstrating functional outcomes equivalent to bone-patellar tendon-bone and hamstring tendon autografts, together with a consistently favourable donor-site morbidity profile and, in several meta-analyses, a lower pooled re-rupture rate than hamstring tendon autograft. Its role in paediatric, adolescent, and revision ACL reconstruction is expanding on the strength of encouraging cohort data. The principal evidence gap is long-term durability beyond five years, where comparative data remain sparse; continued long-term follow-up and standardised outcome reporting across graft types should further clarify where quadriceps tendon autograft fits within contemporary ACL reconstruction practice.

References

1. Sanders, T.L., Maradit Kremers, H., Bryan, A.J., Larson, D.R., Dahm, D.L., Levy, B.A., Stuart, M.J., Krych, A.J. (2016) Incidence of anterior cruciate ligament tears and reconstruction: a 21-year population-based study. American
2. Fulkerson, J.P., Langeland, R. (1995) An alternative cruciate reconstruction graft: the central quadriceps tendon. Arthroscopy, 11(2): 252-254.
3. Slone, H.S., Romine, S.E., Premkumar, A., Xerogeanes, J.W. (2015) Quadriceps tendon autograft for anterior cruciate ligament reconstruction: a comprehensive review of current literature and systematic review of clinical results. Arthroscopy, 31(3): 541-554.
4. Stäubli, H.U., Schatzmann, L., Brunner, P., Rincón, L., Nolte, L.P. (1996) Quadriceps tendon and patellar ligament: cryosectional anatomy and structural properties in young adults. Knee Surgery, Sports Traumatology, Arthroscopy, 4(2): 100-110.
5. Harris, N.L., Smith, D.A., Lamoreaux, L., Purnell, M. (1997) Central quadriceps tendon for anterior cruciate ligament reconstruction. Part I: Morphometric and biomechanical evaluation. American Journal of Sports Medicine, 25(1): 23-28.
6. Xerogeanes, J.W., Mitchell, P.M., Karasev, P.A., Kolesov, I.A., Romine, S.E. (2013) Anatomic and morphological evaluation of the quadriceps tendon using 3-dimensional magnetic resonance imaging reconstruction: applications for anterior cruciate ligament autograft choice and procurement. American Journal of Sports Medicine, 41(10): 2392-2399.
7. Sasaki, N., Farraro, K.F., Kim, K.E., Woo, S.L-Y. (2014) Biomechanical evaluation of the quadriceps tendon autograft for anterior cruciate ligament reconstruction. American Journal of Sports Medicine, 42(3): 723-730.
8. Fink, C., Herbst, E., Abermann, E., Hepperger, C., Hoser, C. (2014) Minimally invasive harvest of a quadriceps tendon graft with or without a bone block. Arthroscopy Techniques, 3(4): e509-e513.
9. Kim, S.J., Kumar, P., Oh, K.S. (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.
10. Lee, S., Seong, S.C., Jo, H., Park, Y.K., Lee, M.C. (2004) Outcome of anterior cruciate ligament reconstruction using quadriceps tendon autograft. Arthroscopy, 20(8): 795-802.
11. Lund, B., Nielsen, T., Faunø, P., Christiansen, S.E., Lind, M. (2014) Is quadriceps tendon a better graft choice than patellar tendon? A prospective randomized study. Arthroscopy, 30(5): 593-598.
12. Han, H.S., Seong, S.C., Lee, S., Lee, M.C. (2008) Anterior cruciate ligament reconstruction: quadriceps versus patellar autograft. Clinical Orthopaedics and Related Research, 466(1): 198-204.
13. Runer, A., Wierer, G., Herbst, E., Hepperger, C., Herbort, M., Gföller, 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 Surgery, Sports Traumatology, Arthroscopy, 26(2): 605-614.
14. 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. American Journal of Sports Medicine, 45(6): 1326-1332.
15. 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. American Journal of Sports Medicine, 47(14):
16. Tan, T.K., Subramaniam, A.G., Ebert, J.R., Radic, R. (2022) Quadriceps tendon versus hamstring tendon autografts for anterior cruciate ligament reconstruction: a systematic review and meta-analysis. American Journal of Sports Medicine, 50(14): 3974-3986.
17. 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. American Journal of Sports Medicine, 50(12):
18. Kunze, K.N., Moran, J., Polce, E.M., Pareek, A., Strickland, S.M., Williams, R.J. (2023) Lower donor site morbidity with hamstring and quadriceps tendon autograft compared with bone-patellar tendon-bone autograft after anterior cruciate ligament reconstruction: a systematic review and network meta-analysis of randomized controlled trials. Knee Surgery, Sports Traumatology, Arthroscopy, 31(8):
19. 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. Archives of Orthopaedic and Trauma Surgery, 140(10): 1465-1474.
20. Aitchison, A.H., Alcoloumbre, D., Mintz, D.N., Hidalgo Perea, S., Nguyen, J.T., Cordasco, F.A., Green, D.W. (2021) MRI signal intensity of quadriceps tendon autograft and hamstring tendon autograft 1 year after anterior cruciate ligament reconstruction in adolescent athletes. American
21. Retzky, J.S., Chipman, D.E., Mintz, D.N., Cordasco, F.A., Green, D.W. (2024) Association of lateral extra-articular tenodesis with improved graft maturity on MRI 2 years after ACL reconstruction with quadriceps tendon autograft in skeletally immature athletes. Orthopaedic Journal of Sports Medicine, 12(1): 23259671231211885.
22. Hurley, E.T., Mojica, E.S., Kanakamedala, A.C., Meislin, R.J., Strauss, E.J., Campbell, K.A., Alaia, M.J. (2022) Quadriceps tendon has a lower re-rupture rate than hamstring tendon autograft for anterior cruciate ligament reconstruction - a meta-analysis. Journal of ISAKOS, 7(2): 87-93.
23. Yang, J.S., Prentice, H.A., Reyes, C.E., Lehman, C.R., Maletis, G.B. (2024) Risk of revision and reoperation after quadriceps tendon autograft ACL reconstruction compared with patellar tendon and hamstring autografts in a US cohort of 21,973 patients. American Journal of Sports Medicine, 52(3): 670-681.
24. Kurkowski, S.C., Thimmesch, M.J., Murphy, M., Kuechly, H.A., Emmert, A.S., Grawe, B. (2025) Uncovering the state of current data on quadriceps tendon autograft use versus bone-patellar tendon-bone and hamstring tendon autografts in anterior cruciate ligament reconstruction at ≥5 years after surgery: a systematic review and meta-analysis. American Journal of Sports Medicine, 53(7):
25. Jackson, G.R., Mameri, E.S., Tuthill, T., Wessels, M., Asif, S., Sugrañes, J., Batra, A.K., McCormick, J.R., Obioha, O.A., Kaplan, D.J., Knapik, D.M., Verma, N.N., Chahla, J. (2023) Adverse events and complications after primary ACL reconstruction with quadriceps tendon autograft: a systematic review. Orthopaedic Journal of Sports Medicine, 11(12): 23259671231199728.
26. Meena, A., Farinelli, L., de Sa, D., D'Ambrosi, R., Hoser, C., Abermann, E., Herbort, M., Fink, C. (2025) Comparison of clinical outcomes, revision rates, and sports participation between hamstring and quadriceps tendon autografts for anterior cruciate ligament reconstruction in pediatric and adolescent patients: a retrospective cohort study. American
27. Hunnicutt, J.L., Xerogeanes, J.W., Slone, H.S. (2021) Revision anterior cruciate ligament reconstruction with the all-soft tissue quadriceps tendon autograft has acceptable early and intermediate-term outcomes. Arthroscopy, 37(11):
28. Brinkman, J.C., Tummala, S.V., Moore, M.L., Economopoulos, K.J. (2022) All-soft tissue quadriceps tendon autograft in revision anterior cruciate ligament reconstruction in athletes: comparison to bone-patellar tendon-bone autograft with at least a 2-year follow-up. American Journal of Sports Medicine, 50(14): 3770-3777.