Comparative outcomes of full‐, partial‐ and superficial quadriceps tendon grafts in anterior cruciate ligament reconstruction: A PRISMA systematic review

PURPOSE: Quadriceps tendon (QT) autografts are favoured in anterior cruciate ligament (ACL) reconstruction for their biomechanical properties, yet outcomes among variants-full-thickness (F-QT), partial-thickness (P-QT) and isolated rectus femoris (RF) grafts-remain unclear. The primary aim was to compare failure rates and knee stability among all-soft tissue QT graft variants. METHODS: Following PRISMA 2020 guidelines, four databases were searched from inception through June 2025. Included studies (published 2019-2025) reported outcomes for F-QT, P-QT, or RF grafts. After screening 2214 records, 13 studies (n = 427 patients) with a mean follow-up of 24-48 months (level of evidence I-IV) were included. Risk of bias was assessed via the National Heart, Lung and Blood Institute (NHLBI) tools. RESULTS: F-QT grafts (n = 342) showed low failure (0%-5.1%), excellent stability (KT-1000: 0.6-1.3 mm; 90.7%-100% negative Lachman) and improved patient-reported outcome measures (ΔIKDC: +39.4; ΔLysholm: +33.6) but had significant quadriceps deficits (↓26%-31% isokinetic performance). Complications included haematoma (12%) and arthrofibrosis (6%-12.5%). P-QT grafts (n = 57) had minimal strength deficits and a 2.3% failure rate. RF grafts (n = 28) showed a 7.1% failure rate. No infections or fractures were reported. CONCLUSION: F-QT autografts provide reliable stability. Evidence suggests P-QT grafts may better preserve quadriceps strength, while RF grafts appear to carry a higher failure risk. Long-term evidence remains limited, necessitating further high-quality comparative studies. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV studies.