Purpose
To compare the outcomes after anterior cruciate ligament reconstruction (ACLR) with either a quadriceps tendon bone (QTB) graft or an all soft-tissue quadriceps tendon (ASTQT) graft and to compare QTB versus ASTQT graft options, including return to play, patient-reported outcome scores, and complication rates.
Methods
A systematic review was conducted by searching PubMed, Embase, SCOPUS, and Cochrane databases for studies published between 2003 and 2023, focusing on outcomes of quadriceps tendon autograft in ACLR.
Results
In total, 37 studies with a total of 39 cohorts (n = 2,647) met inclusion criteria. The studies included 22 cohorts (n = 1,825 patients) for QTB and 17 cohorts (n = 822 patients) for ASTQT. Patients who underwent ACLR with ASTQT graft had a greater rate of return to play compared with those with a QTB (84% to 90% vs 45%-85%). Between ASTQT and QTB graft constructs, International Knee Documentation Committee scores (77.4 to 94.8 vs 71.2 to 92), Lysholm scores (85-95.5 vs 86-96.1), Knee injury and Osteoarthritis Outcome Score-Pain (88.9-89.7 vs 90-90.7), return-to-play times (269.2-319.4 days vs 337.6 days), and revision rates (2.3%-12.8% vs 0%-2.9%) were similar.
Conclusions
Our analysis shows a greater return-to-play rate in patients who underwent ACLR with an ASTQT compared with QTB graft. No differences were found in patient-reported outcome scores or revision rates.
Level of Evidence
Level IV, systematic review of Level I-IV studies.
The anterior cruciate ligament (ACL) is a band of dense connective tissue connecting the intercondylar notch of the lateral femoral condyle and the anterior tibial plateau. The ACL resists excessive anterior translation and rotational forces of the tibia relative to the femur. Noncontact mechanisms account for 70% of ACL injuries whereas direct contact injuries account for the rest. The incidence of ACL injuries is greater than 1 in 3,500 people per year. After an ACL tear, it is imperative to treat the injury to prevent knee instability and maintain the natural function of the ACL. It is estimated that 400,000 anterior cruciate ligament reconstructions (ACLRs) occur in the United States annually, at a cost of $1 billion per year. Long-term postoperative osteoarthritis is associated with ACLR. Only 69% of female athletes return to sport after ACLR. There is interest in improving ACL graft selections and reconstruction techniques to improve long-term patient outcomes and return-to-play rates after surgery.
When examining the ACL grafts available, there is great variability in the graft that the surgeon may choose for a specific patient. There is currently no consensus on the best graft to use during ACLR, indicating further research needs to be conducted on quadriceps tendon autografts. Recent studies have indicated that quadriceps tendon autografts perform as well as bone−patellar tendon−bone autografts in graft survival, functional outcomes, and stability, with lower donor-site morbidity also reported. It is still not known whether a bone block should be used with a quadriceps tendon autograft because the complications and outcome data are heterogeneous. The purpose of this study was to compare the outcomes after ACLR with either a quadriceps tendon bone (QTB) graft or an all soft-tissue quadriceps tendon (ASTQT) graft. It was hypothesized that ASTQT would provide improved return to play, revision rates, and patient-reported knee outcomes scores.
Methods
Study Eligibility
Studies that included patients undergoing ACLR with either the use of a ASTQT autograft or the use of a QTB and reported return-to-play rates, revision rates, and patient-reported knee outcomes scores were eligible for inclusion. Nonrandomized studies were eligible for this systematic review to increase the sample size and power of the analysis because of the limited published literature with a randomized control trial design.
Literature Search and Screening
This systematic review study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 Checklist Guidelines ( Fig 1 ). The search strategy for this systematic review involved one author searching 4 different databases (PubMed, Embase, SCOPUS, and Cochrane databases) for studies published between 2003 and 2023. PubMed and Embase were searched to identify studies focusing on outcomes in ACLR, comparing soft-tissue ASTQT grafts versus QTB. The research question, inclusion criteria, and exclusion criteria were decided before conducting the literature review. The key terms “quadriceps tendon autograft” and “ACL reconstruction” were used in the search of the databases. Duplicates were removed and filters were applied to view studies evaluating human subjects, adults, and published articles (preprints were excluded) in English. Three reviewers (W.W., D.F., and J.H.) evaluated each study’s title, abstract, and/or full text to determine whether a study met the inclusion and exclusion criteria of the review. Each individual then excluded articles from the initial screening folder on the basis of a more refined set of exclusion criteria that were predetermined collaboratively and listed below. No automation tools were used. The following exclusion criteria were ultimately used in primary and secondary screening processes: not ACLR; not quadricep tendon autograft; not 18+ years; systematic review articles; meta-analysis articles; biomechanical studies; abstracts; abstracts; case series and case report studies with a cohort of ≤3 patients; book chapters; cadaveric studies; editorial articles; literature reviews; expert opinions; surgical technique papers; instructional papers; revision surgery; conference reviews; and articles that didn’t report on any post-reconstruction outcomes of interest. The remaining folders and studies ( Table 1 ) ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, were compared and analyzed to arrive at a final group of investigations. The risk of bias in the studies were evaluated with the Risk Of Bias In Non-randomized Studies– of Interventions assessment tool ( Appendix Fig 1 , available at www.arthroscopyjournal.org ).
Complete PRISMA flow diagram showing the identification, screening, eligibility, and inclusion process. Created with permission from: Haddaway NR, Page MJ, Pritchard CC, McGuinness LA. PRISMA2020: An R package and Shiny app for producing PRISMA
2020-compliant flow diagrams, with interactivity for optimised digital transparency and open
synthesis. Campbell Syst Rev 2022;18:e1230. (PRISMA, Preferred Reporting Items for Systematic reviews and Meta-Analyses.).
Table 1
Systematic Review: Functional Knee Outcome Scores and Tegner Activity Level
| Group | Study | IKDC | SANE | Lysholm | KOOS–QOL | KOOS–Pain | Tegner |
|---|---|---|---|---|---|---|---|
| QTB | Akoto et al., 2019 | 86.4 ± 14.2 | NA | NA | NA | NA | 7.6 ± 1.8 |
| QTB | Barié et al., 2020 | 92.0 ± 11.5 | NA | 95.6 ± 7.8 | NA | NA | 6.0 ± NA |
| QTB | Pomenta Bastidas et al., 2022 | 86.3 ± 6.8 | NA | 96.1 ± 2.2 | NA | NA | 5.0 ± 1.0 |
| QTB | Chen et al., 2006 | 91% normal or nearly normal | NA | 93.0 ± 7.9 | NA | NA | NA |
| QTB | Fu et al., 2019 | 89.5 ± 10.3 | NA | NA | NA | NA | NA |
| QTB | Geib et al., 2009 |
Grade A:
23 Grade B: 20 |
NA | NA | NA | NA | NA |
| QTB | Gorschewsky et al., 2007 | 90% good or very good | NA | 94 ± NA | NA | NA | NA |
| QTB | Gorschewsky et al., 2007 | 83% normal or nearly normal | NA | 94 ± 9 | NA | NA | NA |
| QTB | Han et al., 2008 |
92%
Grade A or B |
NA | 91.5 ± NA | NA | NA | NA |
| QTB | Horstmann et al., 2022 | 89.3 ± 12.2 | NA | 90.4 ± 11.9 | NA | NA | NA |
| QTB | Horteur et al., 2020 | NA | NA | NA | NA | NA | NA |
| QTB | Irrgang et al., 2021 | NA | NA | NA | NA | NA | NA |
| QTB | Kim et al., 2018 | 71.2 ± 9.6 | NA | 89.7 ± 8.9 | NA | NA | 4.2 ± 1.3 |
| QTB | Lee et al., 2021 | 81.0 ± 8.4 | NA | 89.8 ± 8.3 | NA | NA | 4.4 ± 1.3 |
| QTB | Lee et al., 2016 | 80.2 ± NA | NA | 92.1 ± NA | NA | NA | 4.7 |
| QTB | Lee et al., 2007 |
87% grade
A and B |
NA | 90.0 ± NA | NA | NA | NA |
| QTB | Lund et al., 2014 | 84.0 ± 13.0 | NA | NA | 82.0 ± 16.0 | 90.0 ± 10.0 | NA |
| QTB | Mouarbes et al., 2020 | NA | NA | 90.1 ± 10.1 | NA | 90.7 ± 7.2 | NA |
| QTB | Runer et al., 2020 | NA | NA | 86.0 ± 22.3 n = 114 | NA | NA | 6.2 ± 2.0 n = 114 |
| QTB | Setliff et al., 2023 | 80.9 ± 20.4 | NA | NA | NA | NA | NA |
| QTB | Sinding et al., 2020 | 76.0 ± 17 | NA | NA | NA | NA | NA |
| QTB | Sofu et al., 2013 | NA | NA |
<64: 1
65-83: 2 84-94: 14 95-100: 6 |
NA | NA | NA |
| QT | Buescu et al., 2017 | NA | NA | NA | NA | NA | NA |
| QT | Cavaignac et al., 2017 | 84.0 ± 13.0 | NA | 89.0 ± 6.9 | 78.0 ± 14.7 | NA | 5.9 ± 1.4 |
| QT | Farinelli et al., 2023 | NA | NA | NA | NA | NA | NA |
| QT | Geib et al., 2009 |
A: 18
B: 7 |
NA | NA | NA | NA | NA |
| QT | Hogan et al., 2021 | 77.4 ± 24.6 n = 19 | 83.0 ± 16.8 | NA | NA | 89.7 ± 16.3 n = 30 | 5.2 ± 2.7 n = 20 |
| QT | Hunnicutt et al., 2019 |
81.6 [67.1,
94.3] |
NA | 85.0 [57, 100] | 62.5 [18.8, 93.8] |
88.9 [72.2,
100.0] |
6.0 [4, 9] |
| QT | Iriuchishima et al., 2017 |
Grade A:
18 Grade B: 2 |
NA | NA | NA | NA | NA |
| QT | Johnston et al., 2022 | 88.5 ± 11.9 | NA | NA | 73.0 ± 19.0 | NA | NA |
| QT | Martin-Alguacil et al., 2018 | NA | NA | NA | NA | NA | NA |
| QT | Perez et al., 2019 | 94.8 (IQR 7.6) | NA | 95.0 (IQR 9) | NA | NA | 6 (IQR 2.5) |
| QT | Pichler et al., 2022 | 93.9 ± NA | NA | 95.5 ± NA | NA | NA | 5.0 ± NA |
| QT | Schmücker et al., 2021 | NA | NA | NA | NA | NA | NA |
| QT | Setliff et al., 2023 | 81.0 ± 18.9 | NA | NA | NA | NA | NA |
| QT | Theut et al., 2003 | 86 ± NA | NA | NA | NA | NA | NA |
| QT | Tirupathi et al., 2019 | NA | NA | NA | NA | NA | NA |
| QT | Todor et al., 2019 | NA | NA | 89.2 ± 10.0 | NA | NA | NA |
IKDC, International Knee Documentation Committee; KOOS, Knee injury and Osteoarthritis Outcome Score; QT, quadriceps tendon; QTB, quadriceps tendon bone; SANE, Single Assessment Numeric Evaluation.
Data Extraction
Three reviewers (W.W., D.F., J.H.) independently evaluated each study article and extracted the relevant data into a spreadsheet. No automation tools were used in the process. All results extracted were checked by the same reviewers independently. If disagreements arose, they were discussed between all 3 reviewers until a consensus was determined. All disagreements were addressed. The final group of studies all reported outcome measures on either ASTQT grafts, QTB grafts, or both. The outcomes of interest for which data were sought included a return-to-play rates, revision rates, and knee outcome scores.
Analysis
This systematic review investigated outcomes from ACLR with quadriceps tendon graft comparing QTB versus ASTQT. The study focused on the return-to-play metrics, complications/morbidities, functional knee outcome scores, and pain levels, if applicable. There were 37 studies with a total of 39 cohorts (n = 2,647) included in the descriptive tables. The studies included 22 cohorts (n = 1,825) for QTB and 17 cohorts (n = 822) for QT. All outcome measures were compared using ranges from results of each included study to provide a qualitative comparison.
Results
In total, 733 articles were identified in the initial search of databases. After an initial screening of titles and abstracts, we included 125 articles on the basis of the exclusion criteria. After full-text screening, a total of 63 studies were included for the review portion of our study; however, only 37 studies were included in the final analysis ( Tables 2 and 3 ). ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, Most studies were excluded from the analysis portion of the study because they were duplicates, abstracts, did not evaluate quadriceps tendon autografts, or did not evaluate the specified outcome measures ( Fig 1 ).
Table 2
Included Study Designs
| Category (QTB or ASTQT) | Citation | LOE | Years | Comparison Group | Prospective or Retrospective | Adjust for Confounding Variables |
|---|---|---|---|---|---|---|
| ASTQT | Buescu et al., 2017 | I | 10/2013-05/2015 | Hamstring tendon autograft | Prospective longitudinal randomized parallel clinical trial | No significant differences were found between groups for BMI or age. |
| ASTQT | Cavaignac et al., 2017 | III | 01/01/2012-12/31/2012 | Hamstring tendon autograft | Prospective cohort | No significant differences were found between groups for age, BMI, sex ratio, follow-up, Tegner preoperative score, or time between injury and surgery. |
| ASTQT | Farinelli et al., 2023 | IV | 09/2018-05/2022 | No comparison group | Retrospective case series | NA |
| ASTQT | Hogan et al., 2021 | III | 2011-2019 | BPTB autograft | Retrospective cohort |
No significant differences were found between groups for age y, sex (% female), BMI, ethnicity (% non-White), laterality (% left). The BPTB group had a significantly taller measured height (cm). No adjustments were known to be made.
There were no statistically significant differences in baseline PROs, including IKDC, KOOS subsets, PROMIS scores, SANE, Tegner, and Marx. |
| ASTQT | Hunnicutt et al., 2019 | III | 2017-2019 | BPTB autograft | Retrospective cohort | No significant differences were found between groups for sex, age height, weight, BMI, time since surgery, preinjury Tegner score, postoperative Tegner score |
| ASTQT | Iriuchishima et al., 2017 | III | No comparison group | Case-control | NA | |
| ASTQT | Johnston et al., 2022 | III | 07/2014-06/2018 | Hamstring tendon autograft matched cohort | Retrospective matched cohort | No significant differences were found between groups for Age at surgery, gender (F: M), height (cm), weight (kg), preinjury Marx scale |
| ASTQT | Joseph et al., 2006 | II | BPTB autograft, semitendinosus/gracilis autograft | Prospective cohort | No difference existed in age or gender between the groups. | |
| ASTQT | Martin-Alguacil et al., 2018 | I | 05/2015-05/2016 | Hamstring tendon autograft | Prospective RCT | No significant differences were found between groups for age, gender, injured side, educational level, tobacco use, alcohol intake, body mass index, time playing |
| ASTQT | Perez et al., 2019 | III | 01/2015-03/2016 | BPTB autograft | Retrospective cohort | No significant differences were found between groups for gender, age at surgery, knee, baseline Tegner activity level, meniscus intervention, follow-up |
| ASTQT | Pichler et al., 2022 | IV | 08/2018- 12/2020 | No comparison group | Retrospective cohort | NA |
| ASTQT | Schmücker et al., 2021 | III | 01/2015- 12/2018 | Hamstring tendon autograft | Retrospective cohort | |
| ASTQT | Theut et al., 2003 | III | 01/1999-05/2000 | No comparison group | Retrospective cohort | NA |
| ASTQT | Tirupathi et al., 2019 | I | 2010-2012 | Hamstring tendon autograft | Retrospective Cohort | No difference existed between the groups. |
| ASTQT | Todor et al., 2019 | III | 01/2013-12/2014 | Hamstring tendon autograft | Retrospective cohort | There were no statistically significant differences between the 2 groups with regard to instrumented Lachman testing, ROM, modified Cincinnati, Lysholm, and SF-36 scores. The data are presented in Table 2 . The only difference between groups, with a statistical significance was, the side-to-side thigh diameter difference. The operated limb had a thinner thigh with a mean 0.43 ± 1.68 cm in the QT group and a mean 1.33 ± 1.65 cm in the hamstring tendon group ( P =.026). |
| QTB | Akoto et al., 2019 | III | 12/2010-03/2013 | ACL reconstruction with interference screw fixation with a 4-fold semitendinosus graft were selected as control group | Retrospective cohort | No statistical differences were found between the two groups in terms of graft failure, infection, contralateral ACL rupture or accompanying meniscus and cartilage injuries. |
| QTB | Barié et al., 2020 | II | 12.2 ± 1.9 mo and 10.3 ± 0.2 yr groups | BPTB autograft | Prospective randomized | The demographic data of the 2 groups showed no significant difference. Due to the exclusion criteria mentioned, accompanying injuries were only found in a few patients (20% of the total group). The frequency of subjects with accompanying injuries did not differ statistically between the 2 groups ( P = 0.519, χ-quadrat test). |
| QTB | Pomenta Bastidas et al., 2022 | II | 10/2014-07/2016 | Hamstring tendon graft | Prospective | NA |
| QTB | Chen et al., 2006 | IV | 1996-1998 | None | Prospective cohort | NA |
| QTB | Fu et al., 2019 | IV | 03/2011-12/2012 | None | Case series | NA |
| QTB | Gorschewsky et al., 2007 | II | 1998-2004 | NA | Cohort | NA |
| QTB | Gorschewsky et al., 2007 | III | 1995-2000 | BPTB autograft | Retrospective | There were no significant differences between the groups in the frequency and treatment of concomitant injuries |
| QTB | Han et al., 2008 | III | 1994-2001 | BPTB autograft | Retrospective therapeutic | Matched for age and gender. |
| QTB | Horstmann et al., 2022 | I | 12/2010-06/2013 | Hamstring tendon autograft | Prospective | NA |
| QTB | Horteur et al., 2020 | III | 01/2017-04/2018 | Hamstring tendon autograft | Retrospective | NA |
| QTB | Irrgang et al., 2021 | II | 03/2011-12/2012 | NA | Clinical Trial | NA |
| QTB | Kim et al., 2018 | III | 2009-2014 | NA | Retrospective | Subjects with a history of previous surgery on the ipsilateral or contralateral knee, or multiligamentous injury that concomitant or staged surgery was needed were excluded and those who had osteoarthritis (Kellgren–Lawrence grade II or above on weight-bearing radiographs) or who underwent high tibial osteotomy at the time of ACL reconstruction were also excluded from this study. |
| QTB | Lee et al., 2021 | IV | 02/1999- 12/2012 | NA | Retrospective case series | Exclusion criteria included previous knee surgery; previous ligamentous injury including chronic ACL tears; and concomitant meniscal or ligamentous injury of the affected knee (other than grade I or II medial collateral ligament injury). |
| QTB | Lee et al., 2016 | III | Hamstring tendon autograft | Retrospective cohort | Each group included 48 patients who were retrospectively matched on the basis of age, sex, and body mass index; there were no statistically significant differences between the 2 groups (all P >.05). | |
| QTB | Lee et al., 2007 | III | 02/1999- 03/2002 | NA | Retrospective | NA |
| QTB | Lee et al., 2007 | IV | 02/1999- 12/2004 | NA | Prospective | NA |
| QTB | Lund et al., 2014 | II | 2005-2009 | BPTB autograft | Prospective controlled clinical | Overall, the baseline characteristics of the patients did not differ significantly between the 2 groups |
| QTB | Mouarbes et al., 2020 | III | 2016-2017 | Hamstring tendon and BPTB allografts | Retrospective | Patients with contralateral knee injury, other ligamentous lesions that required surgical management, previous surgeries on the same knee, or systemic disease were excluded. Meniscal procedures and extra-articular plasty were not considered as exclusion criteria. |
| QTB | Runer et al., 2020 | III | 2010-2016 | Hamstring tendon graft | Prospective Cohort | NA |
| QTB | Sinding et al., 2020 | I | 05/2014- 01/2016 | Semitendinosus gracilis autograft, healthy control group | Prospective | NA |
| QTB | Sofu et al., 2013 | III | 06/2005- 11/2010 | Hamstring tendon graft | Retrospective | NA |
| QTBB vs ASTQT | Geib et al., 2009 | IV | 1996-2005 | BPTB autograft | Retrospective | NA |
| QTBB vs ASTQT | Setliff et al., 2023 | III | QT autograft | Retrospective | NA |
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