Quadriceps Tendon Autograft Versus Bone–Patellar Tendon–Bone and Hamstring Tendon Autografts for Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Abstract

Background:

The best type of autograft for anterior cruciate ligament (ACL) reconstruction remains debatable.

Hypothesis:

Compared with bone–patellar tendon–bone (BPTB) and hamstring tendon (HT) autografts, the quadriceps tendon (QT) autograft has comparable graft survival as well as clinical function and pain outcomes.

Study Design:

Meta-analysis; Level of evidence, 4.

Methods:

A systematic literature search was conducted in PubMed, Embase, Scopus, and the Cochrane Library to July 2020. Randomized controlled trials (RCTs) and observational studies reporting comparisons of QT versus BPTB or HT autografts for ACL reconstruction were included. All analyses were stratified according to study design: RCTs or observational studies.

Results:

A total of 24 studies were included: 7 RCTs and 17 observational studies. The 7 RCTs included 388 patients, and the 17 observational studies included 19,196 patients. No significant differences in graft failure (P = .36), the International Knee Documentation Committee (IKDC) subjective score (P = .39), or the side-to-side difference in stability (P = .60) were noted between QT and BPTB autografts. However, a significant reduction in donor site morbidity was noted in the QT group compared with the BPTB group (risk ratio [RR], 0.17 [95% CI, 0.09-0.33]; P < .001). No significant differences in graft failure (P = .57), the IKDC subjective score (P = .25), or the side-to-side stability difference (P = .98) were noted between QT and HT autografts. However, the QT autograft was associated with a significantly lower rate of donor site morbidity than the HT autograft (RR, 0.60 [95% CI, 0.39-0.93]; P = .02). A similar graft failure rate between the QT and control groups was observed after both early and late full weightbearing, after early and late full range of motion, and after using the QT autograft with a bone plug and all soft tissue QT grafts. However, a significantly lower rate of donor site morbidity was observed in the QT group compared with the control group after both early and late full weightbearing, after early and late full range of motion, and after using the QT autograft with a bone plug and all soft tissue QT grafts. No difference in effect estimates was seen between RCTs and observational studies.

Conclusion:

The QT autograft had comparable graft survival, functional outcomes, and stability outcomes compared with BPTB and HT autografts. However, donor site morbidity was significantly worse with the QT autograft than with BPTB and HT autografts.

Keywords

quadriceps tendon hamstring tendon bone–patellar tendon–bone anterior cruciate ligament reconstruction

An anterior cruciate ligament (ACL) injury is one of the most common ligamentous knee injuries and frequently occurs during sports, such as basketball, handball, and soccer.⁶⁸ For ACL injuries, ACL reconstruction remains the standard of treatment to limit instability and prevent further meniscal and cartilage damage for physically active populations.⁶² However, the optimal autograft choice for ACL reconstruction remains debated. Traditionally, the ACL is primarily reconstructed by 1 of 2 autografts: the hamstring tendon (HT) and the bone–patellar tendon–bone (BPTB).¹¹ The BPTB has traditionally been considered as the gold standard because of low rates of failure and residual instability.⁹⁴ The HT autograft has gained popularity as an alternative option, largely owing to morbidity associated with the BPTB autograft.¹⁸

Although BPTB and HT autografts are widely used today, surgeons have become increasingly aware of the disadvantages of these 2 autografts. Studies have reported that the BPTB autograft was associated with risks for patellar fractures, patellar tendon ruptures, and donor site morbidity,^47,55 whereas the HT autograft could lead to delayed graft incorporation and reduced knee stability.²⁷ Recently, the quadriceps tendon (QT), another alternative graft choice, has been gaining in popularity for ACL reconstruction because of its favorable biomechanics, low donor site morbidity, large cross-sectional area, predictability, ease of harvest, and graft versatility.^19,94 However, to date, the best type of autograft for ACL reconstruction remains debated.

Systematic reviews and meta-analyses of randomized controlled trials (RCTs) are considered the highest level of evidence for the evaluation of treatment effects. However, several reports have shown that little evidence exists for significant differences in effect estimates between RCTs and observational studies.^1,5,13,22,77 The addition of observational studies in meta-analyses increases the sample size, which could enable the evaluation of small treatment effects and infrequent outcome measures. Furthermore, observational studies might provide insight into a variety of populations and long-term effects compared with the usually highly selected patient populations in RCTs.^6,28 Both RCTs and observational studies are increasingly used in orthopaedic trauma meta-analyses for the evaluation of treatment effects.^10,77,95,106

The primary aim of this systematic review and meta-analysis was to compare the QT autograft with HT and BPTB autografts with regard to graft failure, functional and stability outcomes, donor site morbidity, and muscle strength in patients who underwent ACL reconstruction. Second, we sought to evaluate graft failure and donor site morbidity after early and late full weightbearing, after early and late full range of motion, and after using the QT autograft with a bone plug and all soft tissue QT grafts. Finally, we sought to compare effect estimates obtained from RCTs and observational studies.

Methods

This systematic review and meta-analysis was performed and reported according to the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklists.^72,98 A published protocol for this review does not exist.

Search Strategy and Selection Criteria

We last searched PubMed, Embase, Scopus, and the Cochrane Library on July 1, 2020 to identify relevant studies. Electronic searches were performed with the use of Medical Subject Headings (MeSH) terms and corresponding keywords. The search terms used were (keywords “quadriceps graft”, “quadriceps autograft”) and (MeSH “Anterior Cruciate Ligament Reconstruction” and keywords “anterior cruciate ligament reconstruction”, “ACL reconstruction”). Overall, 2 reviewers independently screened titles and abstracts for the eligibility of identified studies. All published comparative studies, including RCTs and observational studies, reporting on the comparison of QT versus BPTB or HT autografts for ACL reconstruction were eligible for inclusion.

After title and abstract screening, the same 2 reviewers independently reviewed full-text articles. Inclusion criteria were primary ACL reconstruction; comparison of QT autograft versus BPTB and/or HT autograft; and reporting of graft failure, donor site morbidity, the International Knee Documentation Committee (IKDC) subjective score, the side-to-side difference in translation, and/or postoperative muscle strength. Exclusion criteria were revision ACL reconstruction, language other than English, no availability of a full-text article, letters, meeting proceedings, case series, and case reports. We had no inclusion restrictions based on the functional rehabilitation protocol. Disagreements on the eligibility of full-text articles were resolved by a consensus or by a discussion with a third reviewer. References of included studies were screened, and backward citation tracking was performed using Web of Science to identify articles not found in the original literature search.

Data Extraction

There were 3 reviewers who extracted data independently using a predefined data extraction file. The following baseline characteristics were extracted from the included studies: first author, year of publication, study design, country in which the study was performed, study period, number of included patients, operative method, full mean follow-up, and outcome data. Studies reporting on patient cohorts described in previously published articles were excluded or merged. The primary outcomes were graft failure and donor site morbidity. Based on the definition of donor site morbidity in the included studies (Appendix Table A1, available in the online version of this article) and previous studies evaluating donor site morbidity after ACL reconstruction,^35,47,71 in this meta-analysis, donor site morbidity was defined as tenderness, numbness, or irritation at the donor site; anterior knee pain; and difficulty in kneeling or knee-walking. Graft failure was defined as the presence of greater than 5 mm of anterior laxity.¹⁰⁴ Secondary outcomes included the IKDC subjective score, side-to-side difference in translation, and postoperative muscle strength.

Quality Assessment

The same 3 reviewers independently assessed the methodological quality of the included studies by using the Methodological Index for Non-Randomized Studies (MINORS).^77,93 The MINORS is a validated instrument for the assessment of methodological quality and clear reporting of nonrandomized surgical studies, resulting in a score ranging from 0 to 24 for comparative studies.^77,93 In this study, the assessment of methodological quality resulted in a score ranging from 0 to 24 for RCTs and prospective cohort studies. The methodological quality of retrospective cohort studies resulted in a score ranging from 0 to 18. The MINORS criteria for the prospective collection of data, loss to follow-up, and prospective calculation of the sample size were not applicable to retrospective cohort studies. Details on the methodological quality assessment are provided in Appendix Table A2. Disagreements were resolved by a consensus.

Statistical Analysis

Dichotomous variables were extracted as the absolute number and percentage, pooled by using the Mantel-Haenszel method, and presented as the risk difference (RD) and risk ratio (RR) with the 95% confidence interval (CI). Continuous variables were extracted as the mean and standard deviation, pooled by using the inverse variance weighting method, and presented as the mean difference (MD) with the 95% CI. Random-effects models were used for all analyses. Statistical heterogeneity between studies was assessed by visual inspection of forest plots and by the I² and χ² statistics for heterogeneity. The Z test for overall effect was used to determine the significance level for treatment effects. All analyses were stratified according to study design: RCTs or observational studies. For the comparison of QT versus BPTB and HT autografts on donor site morbidity, a stratified analysis was also performed according to the different types of donor site morbidity: (1) tenderness, numbness, or irritation at the donor site; (2) anterior knee pain; and (3) difficulty in kneeling or knee-walking. The difference in effect estimates between the 2 subgroups was assessed as described in the Cochrane Handbook for Systematic Reviews of Interventions.³⁹ The significance level for the difference in effect estimates across the subgroups was determined by the test for subgroup differences. The significance level for treatment effects and differences across the subgroups was defined as a P value <.05. Review Manager (version 5.3.5; Cochrane Collaboration) was used for all statistical analyses. Moreover, publication bias was assessed by the Begg and Egger tests with the use of Stata 13.1 (StataCorp).^9,25

Primary Sensitivity Analyses

Sensitivity analyses were performed for the primary outcomes, including studies with an early (≤4 weeks) and late (>4 weeks) full weightbearing status after treatment. Studies reporting on both an early and a late full weightbearing cohort were accordingly divided for sensitivity analysis. An additional sensitivity analysis was performed for the primary outcomes with studies with or without an accelerated functional rehabilitation protocol. Accelerated functional rehabilitation was defined as the start of early full range of motion within 3 weeks after ACL reconstruction. Rehabilitation with functional bracing systems with successive fixed degrees of the knee, which did not allow for free range of motion, was not considered as accelerated rehabilitation. Furthermore, sensitivity analyses were also performed for the primary outcomes, including studies using the QT autograft with a bone plug or all soft tissue QT grafts.

Secondary Sensitivity Analyses

Secondary sensitivity analyses were performed for high-quality studies and year of the study period regarding graft failure and donor site morbidity. High-quality studies were defined as RCTs with a MINORS score of ≥19 (range, 0-24) or observational studies with a MINORS score of ≥14 (range, 0-18).^77,83 Additional sensitivity analyses were performed with studies that included patients after the study year 2010 to account for the development of new anesthesia protocols, operative techniques, and rehabilitation protocols.

Results

Literature Search

Figure 1 shows a flowchart of the literature search and study selection. In the initial search, we identified 1455 records. After an examination of the titles and abstracts, there were 53 potentially eligible studies assessed for inclusion. After reviewing the full text, 2 studies were excluded because of the wrong population (without a QT group)⁸⁵ or outcome (without outcomes including graft failure, donor site morbidity, IKDC subjective score, side-to-side difference, or postoperative muscle strength),⁷⁹ 11 were excluded because they were noncomparative studies,^∥ 3 were excluded because they were commentaries,^26,78,101 2 were excluded because they were study protocols,^20,21 and 9 were excluded because they were reviews.^¶ Of the remaining 26 studies, 2 studies on patient cohorts described in previously published articles were merged with the original studies.^87,92 This resulted in the final inclusion of 24 studies for analyses in this systematic review and meta-analysis: 7 RCTs and 17 observational studies.^#

Figure 1.

PRISMA flow diagram presenting the search and selection of studies comparing the quadriceps tendon (QT) autograft versus hamstring tendon (HT) and bone–patellar tendon–bone (BPTB) autografts for anterior cruciate ligament (ACL) reconstruction.

Study Characteristics

The 24 studies included 19,584 patients, of whom 1788 were treated with a QT autograft, 2470 with a BPTB autograft, and 15,326 with an HT autograft. The overall weighted mean age was 27.3 years: 24 years in the QT group, 25 years in the BPTB group, and 28 years in the HT group. Overall, the studies included 12,055 (62%) male patients. The overall weighted mean follow-up was 24.8 months. Table 1 shows the baseline characteristics for both RCTs and observational studies.

Table 1

Baseline Characteristics of Included Studies^a

		No. of Patients			Age,^b y			Male/Female Sex, n			Body Mass Index,^b kg/m²			Follow-up,
First Author (Year)	Country	QT	HT	BPTB	QT	HT	BPTB	QT	HT	BPTB	QT	HT	BPTB	mo
Randomized controlled trials
Vilchez-Cavazos¹⁰³ (2020)	Mexico	15	16	NA	23.0 ± 2.8	23.0 ± 2.5	NA	NA	NA	NA	NA	NA	NA	12
Lind⁶³ (2020)	Denmark	50	49	NA	27.2 ± 6.4	27.1 ± 6.1	NA	29/21	25/24	NA	24.3 ± 3.4	23.8 ± 2.6	NA	24
Barié⁸ (2020)	Germany	30	NA	30	30.5 ± 7.8	NA	30.6 ± 7.5	17/13	NA	17/13	NA	NA	NA	123.6
Martin-Alguacil⁷⁰ (2018)	Spain	26	25	NA	18.7 ± 3.6	19.2 ± 3.6	NA	23/3	16/9	NA	23.0 ± 2.2	23.5 ± 3.5	NA	12
Buescu¹⁶ (2017)	Romania	24	24	NA	29.2 ± 8.5	27.5 ± 5.6	NA	NA	NA	NA	26.3 ± 4.9	25.7 ± 3.3	NA	0.1
Lund⁶⁶ (2014)	Denmark	26	NA	25	30 ± 9	NA	31 ± 8	21/5	NA	21/4	NA	NA	NA	24
Pigozzi⁸² (2004)	Italy	24	NA	24	33.0 ± 6.5	NA	35.0 ± 4.5	17/7	NA	19/5	NA	NA	NA	6
Observational studies
Lind⁶⁴ (2020)^c	Denmark	531	14,213	1835	26.2	28.1	29.3	372/159	8812/5401	1285/550	NA	NA	NA	24
Mouarbes⁷³ (2020)	France	30	30	30	23.9 ± 7.1	29.0 ± 10.0	24.5 ± 7.2	28/2	19/11	17/13	23.4 ± 3.5	22.9 ± 3.3	21.8 ± 2.6	12
Runer⁸⁶ (2020)^c	Austria	217	658	NA	28.9 ± 11.9	31.4 ± 12.6	NA	127/90	403/255	NA	NA	NA	NA	24
Perez⁸¹ (2019)	USA	28	NA	22	23.1 ± 5.5	NA	21.7 ± 5.8	17/11	NA	19/3	NA	NA	NA	33
Todor¹⁰⁰ (2019)	Romania	39	33	NA	30.6 ± 8.7	28.6 ± 6.7	NA	26/13	23/10	NA	25.2 ± 4.4	25.2 ± 2.9	NA	34
Pennock⁸⁰ (2019)	USA	28	62	NA	14.8 ± 1.3	14.8 ± 1.4	NA	19/9	43/19	NA	21.5 ± 3.2	23.9 ± 5.7	NA	32
Akoto³ (2019)	Germany	41	41	NA	29 ± 10	28 ± 10	NA	32/9	32/9	NA	NA	NA	NA	12
Cavaignac¹⁷ (2017)^c	Switzerland	45	41	NA	32 ± 8	31 ± 9	NA	25/20	24/17	NA	22.4 ± 3.1	24.3 ± 2.9	NA	43
Lee⁵⁸ (2016)	Republic of Korea	48	48	NA	31.1 ± 10.0	29.9 ± 10.3	NA	44/4	44/4	NA	25.1 ± 2.7	24.8 ± 3.2	NA	34.8
Sofu⁹⁶ (2013)	Turkey	23	21	NA	26.8	28.6	NA	21/2	21/0	NA	NA	NA	NA	37.6
Hunnicutt⁴³ (2019)	USA	15	NA	15	25.0 ± 6.8	NA	18.0 ± 4.3	12/3	NA	7/8	24.3 ± 4.4	NA	23.6 ± 5.3	8
Kim⁵³ (2014)	Republic of Korea	142	65	227	NA	NA	NA	NA	NA	NA	NA	NA	NA	24
Kim⁵² (2009)	Republic of Korea	21	NA	27	27.1 ± 9.9	NA	30.2 ± 8.3	18/3	NA	21/6	NA	NA	NA	26
Kim⁵⁰ (2009)	Republic of Korea	29	NA	32	25.3 ± 5.1	NA	28.9 ± 5.9	11/18	NA	14/18	NA	NA	NA	24
Geib²⁹ (2009)	USA	191	NA	30	32	NA	25	100/91	NA	14/16	NA	NA	NA	55.6
Han³⁶ (2008)	Republic of Korea	72	NA	72	27.8 ± 9.0	NA	27.8 ± 9.0	68/4	NA	68/4	NA	NA	NA	41
Gorschewsky³¹ (2007)	Germany	93	NA	101	NA	NA	NA	NA	NA	NA	NA	NA	NA	24

BPTB, bone–patellar tendon–bone; HT, hamstring tendon; NA, not available; QT, quadriceps tendon.

Data are shown as mean ± SD.

Prospective cohort study; all other observational studies are retrospective cohort studies.

The 7 RCTs included 388 (2%) patients; 195 patients were treated with a QT autograft, 79 with a BPTB autograft, and 114 with an HT autograft. The weighted mean age was 28 years: 28 years in the QT group, 32 years in the BPTB group, and 25 years in the HT group; 205 (53%) male patients were included.

The 17 observational studies—3 prospective and 14 retrospective cohort studies—included 19,196 (98%) patients; 1593 patients were treated with a QT autograft, 2391 with a BPTB autograft, and 15,212 with an HT autograft. The weighted mean age in the studies was 27 years: 24 years in the QT group, 25 years in the BPTB group, and 28 years in the HT group; 11,786 (61%) patients were male.

Quality Assessment

The overall mean MINORS score was 15.1 ± 3.1 (range, 10-21). The mean MINORS score for the RCTs was 19.0 ± 1.3 (range, 17-21). The mean MINORS score for the observational studies was 13.5 ± 1.9 (range, 10-17): 16.7 ± 0.6 (range, 16-17) for the prospective cohort studies and 12.8 ± 1.3 (range, 10-14) for the retrospective cohort studies. The details and distribution of MINORS scores are provided in Appendix Table A2 and Table A3, respectively.

QT Versus BPTB

Graft Failure

A comparison of the QT versus BPTB autografts with regard to graft failure was reported in 10 studies: 2 RCTs and 8 observational studies. The overall pooled effect showed that the QT autograft was associated with a similar graft failure rate compared with the BPTB autograft (RR, 1.32 [95% CI, 0.72-2.42]; P = .36; I² = 26%) (Figure 2). The pooled effect of RCTs showed an RR of 0.42 (95% CI, 0.06-2.77; P = .37; I² = 0%), and the pooled effect of observational studies showed an RR of 1.51 (95% CI, 0.81-2.80; P = .19; I² = 27%). Graft failure occurred in 4.1% of patients using the QT autograft compared with 2.0% using the BPTB autograft (RD, 2.1%). We found no significant difference in effect estimates from RCTs and observational studies (test for subgroup differences: P = .21; I² = 37%).

Figure 2.

Forest plot of comparison for graft failure in quadriceps tendon (QT) versus bone–patellar tendon–bone (BPTB). M-H, Mantel-Haenszel.

Donor Site Morbidity

A comparison of the QT versus BPTB autograft on donor site morbidity was reported in 7 studies: 2 RCTs and 5 observational studies. The overall pooled effect showed that the QT autograft was associated with a significant reduction in the donor site morbidity rate compared with the BPTB autograft (RR, 0.17 [95% CI, 0.09-0.33]; P < .001; I² = 62%) (Figure 3). The pooled effect of RCTs showed an RR of 0.05 (95% CI, 0.01-0.40; P = .004; I² = 0%). The pooled effect of observational studies showed an RR of 0.19 (95% CI, 0.09-0.41; P < .001; I² = 73%). Donor site morbidity occurred in 7.6% of patients using the QT autograft compared with 43.3% using the BPTB autograft (RD, –35.7%). We found no significant difference in effect estimates from RCTs and observational studies (test for subgroup differences: P = .24; I² = 26%).

Figure 3.

Forest plot of comparison for donor site morbidity in quadriceps tendon (QT) versus bone–patellar tendon–bone (BPTB). M-H, Mantel-Haenszel.

The stratified analysis indicated that there was a significantly lower rate of tenderness, numbness, or irritation at the donor site for the QT autograft compared with the BPTB autograft (RR, 0.13 [95% CI, 0.03-0.58]; P = .007; I² = 85%) (Figure 4). Additionally, the QT autograft was associated with a significantly lower rate of anterior knee pain compared with the BPTB autograft (RR, 0.16 [95% CI, 0.07-0.37]; P < .0001; I² = 0%) (Figure 4). Finally, the QT autograft was associated with a significantly lower rate of difficulty in kneeling or knee-walking compared with the BPTB autograft (RR, 0.20 [95% CI, 0.07-0.52]; P = .001; I² = 17%) (Figure 4).

Figure 4.

Forest plot of comparison for (1) tenderness, numbness, or irritation at the donor site; (2) anterior knee pain; and (3) difficulty in kneeling or knee-walking in quadriceps tendon (QT) versus bone–patellar tendon–bone (BPTB). M-H, Mantel-Haenszel.

Functional Outcomes

A comparison of the QT versus BPTB autograft in terms of the IKDC subjective score was reported in 5 studies: 2 RCTs and 3 observational studies. The overall pooled effect showed that the QT autograft was associated with a similar IKDC subjective score compared with the BPTB autograft (MD, 1.59 [95% CI, –2.07 to 5.26]; P = .39; I² = 68%) (Appendix Figure A1). The pooled effect of RCTs showed an MD of 7.09 (95% CI, –5.62 to 19.81; P = .27; I² = 86%), and the pooled effect of observational studies showed an MD of –0.59 (95% CI, –1.92 to 0.74; P = .38; I² = 0%), with no significant difference in effect estimates from RCTs and observational studies (test for subgroup differences: P = .24; I² = 28%).

Stability Outcomes

A comparison of the QT versus BPTB autograft in terms of the side-to-side difference in translation was reported in 6 studies: 2 RCTs and 4 observational studies. The overall pooled effect showed that the QT autograft was associated with a similar side-to-side difference compared with the BPTB autograft (MD, –0.10 [95% CI, –0.46 to 0.26]; P = .60; I² = 73%) (Appendix Figure A2). The pooled effect of RCTs showed an MD of 0.04 (95% CI, –0.47 to 0.55; P = .87; I² = 0%), and the pooled effect of observational studies showed an MD of –0.18 (95% CI, –0.65 to 0.30; P = .46; I² = 83%), with no significant difference in effect estimates from RCTs and observational studies (test for subgroup differences: P = .53; I² = 0%).

Muscle Strength

In the study of Pigozzi et al,⁸² the countermovement jump test showed a significantly higher strength deficit in patients with the BPTB autograft than in those with the QT autograft (24% vs 11%, respectively; P < .01) at 6 months’ follow-up. Additionally, on the leg press test, a significantly higher strength deficit was verified in the BPTB group than the QT group (P < .05). However, in the study of Hunnicutt et al,⁴³ there were no significant differences between the groups for any neuromuscular or functional limb symmetry indices, reported as a percentage of the surgical limb over the nonsurgical limb.

QT Versus HT

Graft Failure

A comparison of the QT versus HT autograft on graft failure was reported in 9 studies: 1 RCT and 8 observational studies. The overall pooled effect showed that the QT autograft was associated with a similar graft failure rate compared with the HT autograft (RR, 0.80 [95% CI, 0.38-1.69]; P = .57; I² = 55%) (Figure 5). The effect of the RCT showed an RR of 0.98 (95% CI, 0.06-15.23; P = .99), while the pooled effect of observational studies showed an RR of 0.78 (95% CI, 0.35-1.74; P = .55; I² = 60%). Graft failure occurred in 3.7% of patients using the QT autograft compared with 2.5% using the HT autograft (RD, 1.2%). We found no significant difference in effect estimates from the RCT and observational studies (test for subgroup differences: P = .88; I² = 0%).

Figure 5.

Forest plot of comparison for graft failure in quadriceps tendon (QT) versus hamstring tendon (HT). M-H, Mantel-Haenszel.

Donor Site Morbidity

A comparison of the QT versus HT autograft on donor site morbidity was reported in 6 studies: 2 RCTs and 4 observational studies. The overall pooled effect showed that the QT autograft was associated with a significant reduction in the donor site morbidity rate compared with the HT autograft (RR, 0.60 [95% CI, 0.39-0.93]; P = .02; I² = 14%) (Figure 6). The pooled effect of RCTs showed an RR of 0.53 (95% CI, 0.33-0.84; P = .007; I² = 0%), while the pooled effect of observational studies showed an RR of 0.69 (95% CI, 0.28-1.71; P = .42; I² = 44%). Donor site morbidity occurred in 14.7% of patients using the QT autograft compared with 27.3% using the HT autograft (RD, –12.6%). We found no significant difference in effect estimates from RCTs and observational studies (test for subgroup differences: P = .61; I² = 0%).

Figure 6.

Forest plot of comparison for donor site morbidity in quadriceps tendon (QT) versus hamstring tendon (HT). M-H, Mantel-Haenszel.

The stratified analysis indicated that there was a lower rate of tenderness, numbness, or irritation at the donor site for the QT autograft compared with the HT autograft (RR, 0.23 [95% CI, 0.02-2.78]; P = .25; I² = 69%) (Figure 7), without a significant difference. Additionally, the QT autograft was associated with a lower rate of anterior knee pain compared with the HT autograft (RR, 0.73 [95% CI, 0.38-1.39]; P = .34; I² = 5%) (Figure 7), with no significant difference. Finally, the QT autograft was associated with a lower rate of difficulty in kneeling or knee-walking compared with the HT autograft (RR, 0.67 [95% CI, 0.20-2.19]; P = .50) (Figure 7), without a significant difference.

Figure 7.

Functional Outcomes

A comparison of the QT versus HT autograft on the IKDC subjective score was reported in 6 studies: 2 RCTs and 4 observational studies. The overall pooled effect showed that the QT autograft was associated with a similar IKDC subjective score compared with the HT autograft (MD, –0.54 [95% CI, –1.47 to 0.38]; P = .25; I² = 50%) (Appendix Figure A3). The pooled effect of RCTs showed an MD of 0.16 (95% CI, –1.11 to 1.42; P = .81; I² = 31%), while the pooled effect of observational studies showed an MD of –1.34 (95% CI, –2.69 to 0.01; P = .05; I² = 50%). We found no significant difference in effect estimates from RCTs and observational studies (test for subgroup differences: P = .11; I² = 60%).

Stability Outcomes

A comparison of the QT versus HT autograft on the side-to-side difference was reported in 6 studies: 1 RCT and 5 observational studies. The overall pooled effect showed that the QT autograft was associated with a similar side-to-side difference compared with the HT autograft (MD, 0.01 [95% CI, –0.82 to 0.84]; P = .98; I² = 96%) (Appendix Figure A4). The effect of the RCT showed an MD of –0.10 (95% CI, –0.65 to 0.45; P = .72), while the pooled effect of observational studies showed an MD of 0.03 (95% CI, –0.97 to 1.04; P = .95; I² = 97%). We found no significant difference in effect estimates from the RCT and observational studies (test for subgroup differences: P = .82; I² = 0%).

Muscle Strength

In the study of Martin-Alguacil et al,⁷⁰ ACL reconstruction with a QT graft showed a significantly better isokinetic hamstring:quadriceps (HQ) ratio compared with ACL reconstruction with an HT graft at 12 months’ follow-up in soccer players (P < .01). This higher HQ ratio observed with the QT autograft could be an advantage of this graft over the HT autograft for ACL reconstruction. In the study of Sinding et al,⁹² HQ ratios were also significantly higher with the QT versus HT autograft. Moreover, muscle strength was affected by autograft type at 1 year after ACL reconstruction, with the HT autograft leading to impairments of knee extensor and flexor muscle strength, while the QT autograft resulted in more pronounced impairments of knee extensor muscle strength only. However, in contrast, the study of Cavaignac et al¹⁷ showed that isokinetic strength was similar between the QT and HT groups.

Sensitivity Analyses

The results of primary and secondary sensitivity analyses are presented in Table 2. The primary sensitivity analyses based on (1) studies with an early and late full weightbearing status after treatment, (2) studies with or without an accelerated functional rehabilitation protocol, and (3) studies using the QT autograft with a bone plug or all soft tissue QT grafts were performed for graft failure and donor site morbidity. The findings of graft failure and donor site morbidity were consistent in all primary sensitivity analyses. Similarly, the findings of graft failure and donor site morbidity were also consistent in secondary sensitivity analyses, which were based on high-quality studies and year of the study period.

Table 2

Results of Primary and Secondary Sensitivity Analyses^a

Factor	Graft Failure				Donor Site Morbidity
Factor	No. of Studies	RR (95% CI)	P Value	I², %	No. of Studies	RR (95% CI)	P Value	I², %
Weightbearing status
Early (≤4 weeks) weightbearing status	6	1.12 (0.50-2.51)	.78	0	5	0.21 (0.08-0.56)	.002	63
Late (>4 weeks) weightbearing status	7	0.63 (0.30-1.33)	.23	0	5	0.27 (0.10-0.71)	.009	84
Accelerated functional rehabilitation
Early (≤3 weeks) full range of motion	6	1.25 (0.51-3.07)	.63	0	5	0.17 (0.05-0.61)	.006	62
Late (>3 weeks) full range of motion	4	0.65 (0.33-1.26)	.20	20	3	0.33 (0.16-0.69)	.003	58
Type of QT graft
QT autograft with a bone plug	13	0.67 (0.42-1.08)	.10	0	11	0.34 (0.19-0.63)	<.001	77
All soft tissue QT grafts	4	0.51 (0.14-1.80)	.30	1	4	0.19 (0.05-0.71)	.01	63
High-quality studies	11	1.01 (0.53-1.92)	.98	38	7	0.25 (0.11-0.56)	<.001	61
Study period after the year 2010	12	0.83 (0.44-1.56)	.57	45	10	0.51 (0.30-0.87)	.01	36

QT, quadriceps tendon; RR, risk ratio.

Publication Bias

The Egger and Begg tests were performed to investigate publication bias. The Egger test indicated no evidence of publication bias (P = .053). Similarly, with the Begg test, there was no evidence of substantial publication bias (P = .602).

Discussion

This systematic review and meta-analysis, including both RCTs and observational studies, compared outcomes after using the QT versus BPTB and HT autografts for ACL reconstruction. The pooled effect estimate showed that compared with the BPTB autograft, the QT autograft was associated with a similar graft failure rate, IKDC subjective score, and side-to-side difference in stability. However, the QT autograft resulted in a significantly lower rate of donor site morbidity than the BPTB autograft. Compared with the HT autograft, the pooled effect estimate showed that the QT autograft was associated with a similar graft failure rate, IKDC subjective score, and side-to-side difference. However, the QT autograft resulted in a significantly lower rate of donor site morbidity than the HT autograft. A similar graft failure rate between the QT and control groups was noted after both early and late full weightbearing, after early and late full range of motion, and after using the QT autograft with a bone plug and all soft tissue QT grafts. However, a significantly lower rate of donor site morbidity was observed in the QT group compared with the control group after both early and late full weightbearing, after early and late full range of motion, and after using the QT autograft with a bone plug and all soft tissue QT grafts. No difference in effect estimates was seen between RCTs and observational studies.

Over the past few decades, the use of BPTB autografts for ACL reconstruction has, to a large extent, been replaced by the HT autograft. The problem with donor site morbidity after BPTB harvesting has been a major reason for this shift in graft selection.⁴⁷ There have been 2 meta-analyses that have confirmed that compared with the BPTB autograft, the HT autograft could reduce postoperative complications after ACL reconstruction.^14,30 However, in terms of the comparison between QT and HT autografts, studies reporting donor site morbidity in patients undergoing ACL reconstruction have conveyed conflicting results. A recent study found no significant difference in terms of anterior knee pain between the QT and HT groups.⁷⁴ However, a recent RCT comprising 99 participants found that with regard to donor site morbidity, 27% of patients in the QT group complained of donor site issues compared to 50% in the HT group (P < .04). A similar reduction of almost 50% in the rate of donor site morbidity was also demonstrated.⁶³ Our current review and meta-analysis found that donor site morbidity of the QT autograft (11.2%) was significantly lower than that of HT (27.3%) and BPTB (43.3%) autografts. In the QT group, the most common donor site morbidity was tenderness, numbness, or irritation at the donor site (4.7%), followed by anterior knee pain (3.4%) and difficulty in kneeling or knee-walking (1.4%). In the BPTB group, the most common donor site morbidity was tenderness, numbness, or irritation at the donor site (26.1%), followed by difficulty in kneeling or knee-walking (12.0%) and anterior knee pain (5.2%). In the HT group, the most common donor site morbidity was tenderness, numbness, or irritation at the donor site (15.3%), followed by anterior knee pain (9.2%) and difficulty in kneeling or knee-walking (2.8%) (Appendix Table A4).

Several anatomic articles have assessed the cutaneous nerves at the level of the HT and BPTB incisions, which are mainly innervated by the saphenous nerve.⁸⁸ On exiting the adductor canal, the saphenous nerve divides into 2 branches: the sartorial branch and the infrapatellar branch. The sartorial branch takes a vertical course as it travels down the medial knee behind the sartorius in close association with the gracilis over a length of a few centimeters before becoming subcutaneous by piercing the fascia. It then continues distally with the great saphenous vein to govern sensation of the medial aspect of the leg and ankle.^7,69 The infrapatellar branch of the saphenous nerve innervates the skin of the anterior part of the knee, the proximal lateral part of the lower leg, and part of the knee joint.⁴⁸ Surgery performed on the anteromedial aspect of the knee is usually associated with a risk of iatrogenic injuries to the infrapatellar branch of the saphenous nerve. Therefore, the potential risk of injuries to the infrapatellar branch of the saphenous nerve related to surgical incision of the HT and BPTB is likely to lead to regional donor site morbidity.^7,46,99 This can cause numbness in the area innervated by the nerve, neuropathic pain, and formation of a neuroma.⁴⁸ At the level of the QT incision, anterior cutaneous innervation is supplied mainly by the terminal branch of the intermediate femoral cutaneous nerve.⁴¹ In the study by Geib et al,²⁹ significantly less anterior knee pain and numbness were found in patients treated with a QT graft compared with patients treated with a BPTB graft. Moreover, in the study by Mouarbes et al,⁷³ a significant difference was shown between the QT group and the BPTB and HT groups, with a mean area of hypoesthesia of 8.7 cm² versus 88.2 and 70.3 cm², respectively. Our results confirm the advantage of QT harvesting regarding regional donor site morbidity. This difference can be partially explained by injuries of only the terminal small ramification branches of the intermediate femoral cutaneous nerve at the level of the QT incision, with more serious injuries of the main branch at the level of the HT and BPTB incisions.

Although the QT autograft was used previously primarily in revision ACL surgery, it has many anatomic and biomechanical benefits for primary ACL reconstruction.⁷⁶ The fibers of the BPTB and HT are parallel, while the QT is composed of several layers. The most superficial layer of the QT contains the rectus femoris (RF) tendon, the middle layer contains the vastus medialis oblique (VMO) and vastus lateralis (VL) tendons, and the deep layer contains the vastus intermedius (VI) tendon. The RF and VI tendons have straight fibers directed toward the patella, whereas the VMO and VL tendons have oblique or crossing fibers.^4,65 A biomechanical study reporting on strength of the BPTB, QT, and HT autografts found higher strength of the QT autograft compared with both the BPTB and HT autografts.⁹⁰ Moreover, it was also found that the QT had a cross-sectional area 2 times greater than that of the BPTB.⁹⁰ With ACL autografts, a strong association was noted between a large cross-sectional area and a decreased risk for graft-tunnel mismatch, which can promote the inflow of synovial fluid, tunnel widening, and bone resorption and reduce the rate of graft failure.³⁶ In this study, we found that the QT autograft (3.9%) was associated with a similar rate of graft failure compared with BPTB (2.0%) and HT (2.5%) autografts.

We found no difference in pooled effect estimates from RCTs and observational studies. This is in line with previous reports showing that differences in effect estimates between RCTs and observational studies are small.^{1,13,22,28,77} Observational studies, however, have also been associated with an overestimation of treatment effects compared with RCTs.^38,45 Hemkens et al³⁸ assessed the difference in treatment effect estimates for mortality between observational studies and RCTs. They evaluated 16 observational studies and 36 subsequent RCTs investigating the same clinical questions. Overall, observational studies significantly overestimated the effects of treatment compared with RCTs.³⁸ This overestimation of treatment effects could be explained by the effects of bias and confounding in observational studies.¹⁵ However, overestimates by observational studies could also be explained by the potential selection bias in RCTs, which require strict conditions such as the selection of participants, inclusion/exclusion criteria, randomization method, and outcome measurements. The patient population in daily clinical practice can differ from the often highly selected patient populations in RCTs, a potential source for the discrepancy between treatment effects.^49,102 Nevertheless, observational studies increase the sample size, which can potentially lead to the evaluation of small treatment effects and infrequent outcome measures. Furthermore, the addition of observational studies might provide insight into a variety of populations and long-term effects. These results could improve the representation of daily clinical practice, with various levels of surgical experience and differences in operative techniques, provided that confounding factors have been adequately addressed.^6,28 In this meta-analysis, the pooled effect estimates obtained from RCTs and observational studies were similar. Several orthopaedic trauma meta-analyses including both RCTs and observational studies have shown high-quality observational studies to result in similar treatment effects to those of RCTs.^10,77,95,106 These findings indicate that the effect of potentially unmeasured confounding factors in high-quality observational studies seems relatively small, emphasizing the possible benefits of combining different study designs for the evaluation of objective outcome measures after surgical treatment.

In this meta-analysis, sensitivity analyses were performed for the primary outcomes, including (1) studies with an early and late full weightbearing status after treatment, (2) studies with or without an accelerated functional rehabilitation protocol, (3) studies using the QT autograft with a bone plug or all soft tissue QT grafts, (4) high-quality studies, and (5) year of the study period. The results of sensitivity analyses show that the primary results (graft failure and donor site morbidity) were not affected by all of these different factors, which indicated that the findings of this review could be regarded with a relatively high degree of certainty.⁴⁰

As far as we know, 4 articles have systematically reviewed the clinical studies of ACL reconstruction using a QT autograft.^44,74,75,94 Of these reviews, 3 only summarized the outcomes of the studies and did not perform a statistical analysis or directly compare results between QT and other grafts.^44,75,94 The other, a meta-analysis, was published in 2019 and included 12 comparative studies.⁷⁴ However, in the study, because the authors did not clearly define graft failure, there were several discrepancies in the extracted data.⁷⁴ Moreover, in the meta-analysis by Mouarbes et al,⁷⁴ the data of RCTs and retrospective studies were directly pooled together. Similarly, patients with revision ACL reconstruction and primary ACL reconstruction were also directly pooled together, which goes against the precept of pooling studies with a similar design, population, intervention, control, and outcome in the analysis.⁴⁰ Compared with the previous meta-analysis, our review included 6 new RCTs and 8 new observational comparative studies with a total of 18,125 new patients, which resulted in an increased number of patients available for analysis, thus exceeding previous meta-analyses. The previous meta-analysis reported that the QT autograft was associated with similar donor site morbidity and better functional outcome scores compared with the HT autograft. In contrast with the previous meta-analysis, with the addition of RCTs and observational comparative studies, this review shows that the QT autograft had comparable functional outcomes compared with the HT autograft and that donor site morbidity was significantly lower with the QT autograft than with the HT autograft.

Limitations

Some limitations of this study need to be considered. First, the methodological quality of included studies was assessed by the MINORS criteria, which do not differentiate between randomized and nonrandomized studies. However, unlike other quality assessment tools that focus on a specific study design, the MINORS is externally validated on RCTs and is able to distinguish adequately between study designs, as well-designed randomized trials score higher than well-designed nonrandomized studies, making it a suitable instrument for meta-analyses of different study designs.^10,57,77,93 Moreover, the MINORS includes 12 items, one of which is whether the studies have an appropriate follow-up; therefore, the MINORS has also been extensively used in systematic reviews and meta-analyses to assess the quality of articles on ACL reconstruction with a different length of follow-up.^{23,34,42,91,97} Second, the studies included were heterogeneous in terms of rehabilitation methods, ACL reconstruction techniques, and the type of QT grafts. These factors may potentially influence the outcomes of the patients. In addition, follow-up times of the included RCTs were variable, with only 3 trials with at least 24 months; thus, more RCTs are needed to determine the long-term graft failure rate in the future.

Conclusion

The QT autograft had comparable graft survival, functional outcomes, and stability outcomes compared with the HT and BPTB autografts. However, donor site morbidity was significantly lower with the QT autograft than the HT and BPTB autografts.

Supplemental Material

sj-pdf-1-ajs-10.1177_03635465211030259 – Supplemental material for Quadriceps Tendon Autograft Versus Bone–Patellar Tendon–Bone and Hamstring Tendon Autografts for Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Supplemental material, sj-pdf-1-ajs-10.1177_03635465211030259 for Quadriceps Tendon Autograft Versus Bone–Patellar Tendon–Bone and Hamstring Tendon Autografts for Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis by Wenli Dai, Xi Leng, Jian Wang, Jin Cheng, Xiaoqing Hu and Yingfang Ao in The American Journal of Sports Medicine

Footnotes

Submitted September 24, 2020; accepted March 10, 2021.

The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

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References 19, 24, 32, 33, 51, 54, 56, 59 -61, .

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References 2, 11, 12, 37, 44, 67, 74, 84, .

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References 3, 8, 16, 17, 29, 31, 36, 43, 50, 52, 53, 58, 63, 64, 66, 70, 73, 80 -82, 86, 96, 100, .

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